ignorance, part two

Lets consider a great triumph of medicine, vaccination to prevent smallpox. This innovation is credited to Dr. Edward Jenner, who certainly deserves praise for his work. How did this come to be standard practice?

The observation that people who survived one bout with smallpox were immune to later epidemics of the same type is as old as the disease. In Turkey this led to variolation, inoculation with pus from what was hoped would be a mild case of smallpox. (I have not attempted to trace this to earlier sources. There are many.) Lady Montagu, wife of the British ambassador to Istanbul in 1716-1718 brought news of this back to England. This was not, however, the first report to reach the country.

In America, in 1706, the cleric Cotton Mather heard about a similar procedure from an African slave named Onesimus, who had been inoculated in his youth in Africa (an interesting example of the flow of medical knowledge.) Beyond the Salem witch trials, the controversy over his advocacy of this practice became one of Mather's enduring legacies.

Mather approached several local physicians, but only convinced one, Dr. Zabdiel Boylston, to attempt inoculation in the face of an expanding epidemic. Dr. William Douglass, the only MD in the community, opposed this vehemently. He formed "The Society of Physicians Anti-Inoculators".

The controversy was fanned by the press, including one James Franklin, whom local ministers had jailed for publishing an article "freighted with Nonsense --- Prophaneness, Immorality --- Lyes, Contradictions". While James was jailed, one Benjamin Franklin kept the rhetoric flowing. (Benjamin later changed his opinion on inoculation.)

Beyond such rhetorical bombs the campaign against inoculation included one real bomb thrown into Mather's house. (It failed to explode, sparing the patient in that room.) The note wrapped around it said "Cotton Mather, you dog; I'll inoculate you with this; with a pox to you."

Despite these distractions Mather and Boylston achieved one singular advance. They published a paper showing that the mortality rate for inoculation was only 6 out of 287 inoculated, 2%, versus 842 out of 4917, 14.9%, of those infected naturally. This may have been the first clinical trial of a new medical procedure with careful numerical results ever published.

In 1724 Boylston traveled to England, where he published an account of their trial. He was made a fellow of the Royal Society, an honor also extended to Mather. Significantly, Boylston had never attended medical school because there were none in America.

During epidemics, the odds of surviving if you were inoculated or variolated while healthy were significantly better than if you caught the disease after you were weakened by other factors. Variolation became a risky preventive measure practiced by some English physicians. This could easily be fatal.

In 1765, a Dr. Fewster published a paper observing that infection with cowpox (vaccinia) seemed to prevent later infection by smallpox. Little more about his activities seems to be known. He may have been reporting an observation already known to others.

We don't know that he attempted to use this as in vaccination. Some half a dozen early examples of people vaccinating to prevent smallpox have turned up, but most were not doctors.

Benjamin Jesty, a Dorset farmer, is one who might have inspired Jenner. He successfully vaccinated his wife and children during an epidemic in 1774. Jenner didnt try his famous experiment until 1796.

Jenner tested vaccination with cowpox on a child, James Phipps, then deliberately attempted to infect him with smallpox, which produced no disease. Various ethical concerns about this kind of experiment were foreign to that period, but you have to remember that variolation was an accepted, if risky, medical practice. Jenner went on to test the vaccination procedure on 23 subjects.

How was this treated by his contemporaries? We have satirical cartoons and writings as evidence. What about more serious medical researchers?

This is where Dr. Beddoes reenters our story. He was certainly trying to innovate at his Pneumatic Institute, so he cant be accused of unthinking conservatism. He had also observed that people who lived around cattle were less likely to contract smallpox, and other diseases. He went on to assume this was due to some kind of air emanating from those cattle. He even went to the length of housing patients in one of his clinics next to a field with cattle, (though cartoons and lampoons suggesting they shared rooms with patients are inaccurate.)

He was attempting to expand the miasma theory of disease into a broader theory which included the effect of salubrious airs. This had a long run in the case of sanatoria for tuberculosis, where it did some good without actually curing disease. (You can find the practice in the early twentieth century described in The Magic Mountain (Der Zauberberg) by Thomas Mann.) At the time, Beddoes ideas seemed no more ridiculous than vaccination. Dr. Beddoes himself was skeptical of Jenner.

Jenners approach to prevention of smallpox went on to become standard practice, and I would be exceptionally biased if I said no other doctors supported him in this. He achieved recognition in his own lifetime, and was a member of what became the Royal Society of Medicine.

Progress in his goal of eradicating smallpox was slow, however. Medical authorities did not ban variolation until 1840, by which time it was clear the risks were unjustified. This was 75 years after the first published observation that infection by cowpox prevented smallpox. What the time span tells us is that medical professionals were slower to change their opinions than to die.

What was such intense conservatism protecting? Doctors were not protecting patients from infection, they had no idea what caused it. They werent protecting patients from pain. (A careful depiction of surgery at that time would do nicely for horror films.) Medicines they dispensed could be classified in three general categories: toxic, addictive or useless.

Little had changed since the 16th century, when Montaigne wrote that he paid doctors to keep him company while he was sick, but on no account would he take their medicines. Doctors often had a great deal of education, but their understanding of disease was dominated by ignorance. Little changed for quite some time. Compare these quotations from different centuries:

Some fell by laudanum, and some by steel, and death in ambush lay in every pill. Sir Samuel Garth

"The art of medicine consists of amusing the patient while nature cures the disease. Voltaire

I firmly believe that if the whole material medical could be sunk to the bottom of the sea, it would be all the better for mankind, and all the worse for the sea. Oliver Wendell Holmes

Modern medicine is a negation of health. It isn't organized to serve human health, but only itself, as an institution. It makes more people sick than it heals. Ivan Illyich

Dr. Edward Jenner does not deserve credit for inventing vaccination, or making the discovery that cowpox prevented smallpox. He can't be credited with invention of the clinical trial. What he accomplished was much more difficult -- overcoming opposition by the medical profession.


As a result of private correspondence, I've learned that some think the quotation by Oliver Wendell Holmes, above, came from the Supreme Court Justice. This was actually a quote from his father, a physician, poet and writer responsible for "The Autocrat at the Breakfast Table". So fleeting is fame.

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