From Variolation to Cowpox Vaccination: The First Steps Towards Eradicating Smallpox

*The following blog post was written by Samantha Sandassie, Queen’s University PH.D candidate/teaching fellow

Edward Jenner looms large in the history of vaccination.  Known today as the “father of immunology,” Jenner is most famous for developing a vaccine against smallpox in the 1790s.  The vaccine brilliantly made use of common knowledge.  Milkmaids were known for having noticeably clear and smooth skin.  They had, it seemed, managed to develop an immunity to smallpox by suffering (and surviving) a bout of the much milder cowpox.

As the popular narrative goes, Jenner observed this and speculated that it would be possible for others to develop immunity from smallpox if they were infected successfully with cowpox.  To that end, he collected the pus from cowpox lesions on the arm of a milkmaid named Sarah Nelms and used it to infect the eight year old James Phipps.  James suffered some symptoms and once well, Jenner attempted to infect him again – this time with pus from a smallpox lesion.  Luckily for James, his body had since developed antibodies to counter the virulent disease.[1]  James was deemed immune, smallpox inoculation spread, and the legend of Edward Jenner was born.

L0026138 Edward Jenner. Pastel by John Raphael Smith.
Edward Jenner. Pastel by John Raphael Smith.Wellcome Library, London

Both Europe and Asia were plagued by smallpox for millennia. Ralph Josselin, a seventeenth century English clergyman, noted that of his five children that lived past infancy, four contracted and survived smallpox while the fifth died from it.[2]  No one, not even royalty was spared its devastating effects; in the eighteenth century alone, smallpox claimed the lives of Emperor Joseph I, Luis of Spain, Peter II of Russia, and Louis XV of France.[3]

Smallpox claimed roughly 400,000 European lives in the 18th century and left many of those who survived it blind and/or covered in unsightly pockmarks.[4]  A 1773 letter described one smallpox survivor as “a little, pale, insignificant-looking girl, marked, even to seams, by the smallpox.”[5]  A century later, even Mary Shelley – the author of Frankenstein – suffered the high fevers and itch of smallpox.  She lay bedridden for several days and was, apparently, quite “flattered by the attention…showed her in spite of the remnants of smallpox on her face.”[6]

Coupled with widespread syphilis, this was certainly a time of widespread dermatological markers of disease!

In addition to pustules, the disease brought with it pain, fever, swollen eyes, constipation, exhaustion, “epileptic fits,” and sweating.  If quite serious, Thomas Sydenham wrote (1694), “the sick person becomes lightheaded, vehemently sick and anxious, tosseth his Body, pisseth little and often, and within a few hours expires.”[7]

Sound quite dreadful, doesn’t it?  In a time before widespread vaccination, the vast majority of early modern Europeans had to suffer through (and survive) such symptoms.

This sort of suffering serves to highlight the importance of Jenner’s vaccination and add a heroic element to his story.  But, unfortunately, it also obscures the fact that the actual process of developing and popularizing a successful vaccine was much more complicated than a simple “eureka” moment.

More modern scholarship has moved away from the triumphant Jenner model to examine efforts to eradicate smallpox in 10th century China, in Turkey, and the inoculation attempts by Jenner’s English predecessors.  Indeed, we have evidence that at least six people thought of, and began practicing, inoculation against smallpox with cowpox.[8]

Title page, A treatise upon the small-pox.  Wellcome Library, London.
Title page, A treatise upon the small-pox. Wellcome Library, London.

Did you know that Jenner himself underwent one of these procedures against smallpox as a child?[9]  Jenner was variolated.  That is, as a child, he had the pus from smallpox pustules applied to scratches made in his skin.  The patient would then develop smallpox (hopefully mildly), recover, and prove immune to recurrent infections.

A 1714 article in the Philosophical Transactions of the Royal Society explains that the pus should be collected in a glass vessel and kept in a warm place.  The patient to be variolated would be pricked in a fleshy location (usually arm) with a surgeon’s three-edged needle or a lancet several times until droplets of blood form on the skin.  Thereafter, the blood would be mixed with pus and applied, using a blunt stile, to a freshly made shallow incision (presumably near the initial pricking).  The cut would then be bound for a few hours so that the pus and blood would not leak out.[10]

A few years after the article was published, Lady Mary Wortley Montagu wrote a now famous letter describing the variolation she observed in Constantinople.  In it, she noted that no one had died from the operation and that she intended to “try it on my dear little son.”  Lady Montagu hoped to bring the process to England, but was pessimistic that any physician would popularize the idea if it lessened their potential income from smallpox treatments.[11]

She went on to have her son inoculated in Constantinople and had surgeon Charles Maitland inoculate her daughter Mary upon return to England.

In 1721, Maitland continued his variolation experiments.  On 8 August 1721 he wrote, inviting famed physician Sir Hans Sloane to attend the “Operation of Inoculating the Small Pox on the Prisoners in Newgate.”[12]  The next day he inoculated, via variolation, six prisoners of Newgate prison – all of the men survived and were pardoned their crimes in return for agreeing to be experimented upon.

Further experiments were made upon five orphans from London’s St. James parish at the request of Caroline of Ansbach (the wife of George II).[13]  Caroline was curious as to the efficacy of the process and when the inoculated children survived – despite one also suffering from scrofula – she had her two young daughters Amelia and Caroline inoculated as well.  Interestingly the other children were not variolated as well and some eventually contracted smallpox.  Charles Maitland, incidentally, helped treat Frederick Louis, the Prince of Wales when he contracted smallpox and left a detailed journal of the young prince’s suffering.[14]

Variolation, though undoubtedly helpful in containing spread of smallpox, had its problems.  First, practitioners were unsure of the best method: did you need to purge the patient or give him medication prior to variolation?  Was any post-variolation care necessary?  How much of the smallpox matter should be introduced to the patient?  Was a specific number of entry points necessary?  How large or deep should the incision point be?

In the 1750s smallpox pus began to be introduced through a smaller point rather than a large incision.  Known as the Sutton method, only the tiniest amount of pus was introduced to the patient.  A lancet was dipped in pus then inserted “under the cuticle obliquely in the outer part of the arm, between the scarf and the true skin, barely sufficient to draw blood and not deeper than the sixteenth part of an inch.  The raised skin was then pressed down by the finger without further application of plaster or bandages.”[15]

969-222-4
Hollow-pointed vaccinating lancet, Collection of the Museum of Health Care, 1969.222.4

Sutton’s use of a lancet, a smaller amount of smallpox matter, and a smaller point of entry meant a more comfortable initial experience.  The method was not universal, however, and incisions and even scarificators – repurposed from bloodletting – were used to aid in inoculation.

Through it all the patient still had to suffer through some, though milder, smallpox  symptoms.

Drawings showing smallpox and cowpox inoculation. Wellcome Library, London.
Drawings showing smallpox and cowpox inoculation. Wellcome Library, London.
997002031
Wax model, Joseph Towne, 1850, Collection of the Museum of Health Care, 997002031

The images above speak for themselves.  Jenner’s use of cowpox rather than smallpox was significant.  Cowpox was a much, much milder affliction and those inoculated with it enjoyed subsequent immunity to smallpox and a less severe reaction to the whole process.

Like Lady Montagu and Caroline of Ansbach, many concerned mothers discovered that the brief discomfort caused by Jenner’s inoculation was far preferable to a child’s suffering, disfigurement, and potential death by smallpox.  Though the process had not yet been perfected in the early nineteenth century, Lady Maria Nugent was willing to send to England, from Jamaica, for the vaccine (that is, vials of cowpox pus) so that she could inoculate her month-old daughter for, as she wrote, “it is best not to run the risk of the small-pox.”[16]

The Cow Pock, James Gillray, 1802, Wellcome Library, London
The Cow Pock, James Gillray, 1802, Wellcome Library, London

Not everyone was pleased with Jenner’s popularization of vaccination.  Anti-vaccination protesters suggested that the process was dangerous, that cowpox was equally dreadful, and even – rather nonsensically – that it caused other diseases like syphilis!

Despite these naysayers, and through the continued interest and care from concerned parents, medical practitioners, and scientists, more efficient and effective vaccinations against smallpox were developed subsequently.  Thanks to Jenner – and especially to the earlier variolators – the World Health Organization was able to declare smallpox eradicated in 1980.

For more information on Samantha Sandassie, click here, or check out her blog Panacea: Musing on the History of Medicine. Thank you for your post Samantha! 

[1] Stefan Riedel, “Edward Jenner and the History of Smallpox and Vaccination,” Baylor University Medical Center Proceedings 18,1 (Jan 2005), 25.

[2] Alan Macfarlane, The Family Life of Ralph Josselin, New York: W.W. Norton and Company (1970), 120 & 170.

[3] J.N. Hays, Epidemics and Pandemics: Their Impacts on Human History, Santa Barbara, California: ABC-CLIO (2005), 152.

[4] N. Barquet and P. Domingo, “Smallpox: the Triumph Over the Most Terrible of the Ministers of Death,” Annals of Internal Medicine 128,9 (May 1998), 635-42.

[5] Seward, Anna, 1747-1809, Letter from Anna Seward to Giovanni Saville, June 10, 1793, in Letters of Anna Seward: Written Between the Years 1784 and 1807, vol. 3. Constable, A., ed.. Edinburgh, Scotland: Archibald Constable (1811), 397.

[6] Shelley, Mary Wollstonecraft Godwin, 1797-1851, Diary of Mary Wollstonecraft Godwin Shelley, February, 1828, in The Journals of Mary Shelley, 1814-1844, Vol. 2: 1822-1844. Feldman, Paula R. and Scott-Kilvert, Diana, eds.. New York, NY: Oxford University Press (1987), 735.

[7] Thomas Sydenham, The Compleat Method of Curing Almost All Diseases, London: Randal Taylor (1694), 29-31.

[8] CP Gross and KA Sepkowitz, “The Myth of the Medical Breakthrough: Smallpox, Vaccination, and Jenner Reconsidered,” International Journal of Infectious Diseases 3,1 (Jul-Sep 1998), 54-60 and F. Fenner, “Smallpox: Emergence, Global Spread, and Eradication,” History and Philosophy of the Life SciencesI 15,3 (1993), 397-420. See especially: C. Plett, “Peter Plett and Other Discoverers of Cowpox Vaccination Before Edward Jenner,” Sudhoffs Arch. 90,2 (2006), 219-232.

[9] Derrick Baxby, ‘Jenner, Edward (1749–1823)’, Oxford Dictionary of National Biography, Oxford University Press, 2004; online edn, May 2009.

[10] Emanuel Timonius and John Woodward, “An Account, or History, of the Procuring the Small Pox by Incision, or Inoculation; As It Has for Some Time Been Practised at Constantinople,” Phil Trans. 29 (1714), 73-74.

[11] Montagu, Lady Mary Pierrepont Wortley, 1689-1762, Letter from Lady Mary Pierrepont Wortley Montagu, April 01, 1717, in The Letters and Works of Lady Mary Wortley Montagu, vol. 1. Wharncliffe, Lord, ed.. London, England: Richard Bentley (1837), 424.

[12] BL MS Sloane 4076 f.96.

[13] BL MS Sloane 4076 f.331.

[14] BL MS Sloane 4076 f.98.

[15] The History of Inoculation and Vaccination for the Prevention and Treatment of Disease, London: Burroughs Wellcome & Co. (1913), 48.

[16] Nugent, Lady Maria Skinner, 1771(?)-1834, Diary of Maria Skinner Nugent, October, 1803, in A Journal of a Voyage to, and Residence in, the Island of Jamaica, from 1801 to 1805, and of Subsequent Events in England from 1805 to 1811, vol. 1. London, England: T. & W. Boone (1839), 500.

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