User:NHIS3212A/Boston Smallpox Inoculation

Smallpox Inoculation Controversy
The practice of smallpox inoculation (as opposed to the later practice of vaccination) was developed centuries ago in Africa and Asia. Spreading its reach in seventeenth-century Turkey, inoculation or, rather, variolation involved infecting a person through a cut in the skin with exudate from a patient with a relatively mild case of smallpox (variola), in order to bring about a manageable and recoverable infection that will provide later immunity.

By the beginning of the eighteenth century, the Royal Society in England was discussing the practice of inoculation, and the smallpox epidemic in 1713 spurred further interest. It was not until 1721, however, that England recorded its first case of inoculation.

Lady Mary Wortley Montagu, an English aristocrat, observed the process of "engrafting" while in Adrianople in western Turkey in 1718. This was an annual event where an "old woman comes with a nut-shell full of the matter of the best sort of small-pox," which she applied on the head of a needle into several of a patient's veins. In eight days, Montague reported, fever and a mild case of pox would set in, usually requiring two days in bed, after which the patient would be immune. "You may believe I am well satisfied of the safety of this experiment," Montague wrote, "since I intend to try it on my dear little son." (It's unclear whether the son was actually inoculated at that time, however.)

Montagu's daughter was the first recorded inoculation in England in April 1721, and another child was inoculated in May. Subsequent inoculations were practiced on volunteering felons, and Princess Caroline of Great Britain had her daughters inoculated in April 1722.

Smallpox and Inoculation in Early New England
Smallpox was a serious threat in colonial America, most devastatingly to Native Americans, but also to Anglo-American settlers. New England suffered smallpox epidemics in 1677, 1689-90, and 1702. It was highly contagious, and mortality could reach as high as 30 percent or more.

Boston had been plagued by smallpox outbreaks in 1690 and 1702. During this era, public authorities in Massachusetts dealt with the threat primarily by means of quarantine. Incoming ships were quarantined in Boston harbor, and any smallpox patients in town were held under guard or in a "pesthouse."

In 1706 a slave, Onesimus, explained to Rev. Cotton Mather how he had been inoculated as a child in Africa. Mather was fascinated by the idea. By July 1716, Mather had read an endorsement of inoculation by Dr. Emanuel Timonius of Constantinople in the Philosophical Transactions. Mather then declared, in a letter to Dr. John Woodward of Gresham College in London, that he planned to press Boston's doctors to adopt the practice of inoculation should smallpox reach the colony again.

By 1721, a whole generation of young Bostonians was disease-prone and memories of the last epidemic's horrors had by and large disappeared. On April 22 of that year, the HMS Seahorse arrived from the West Indies carrying smallpox on board. Despite attempts to protect the town through quarantine, eight known cases of smallpox appeared in Boston by May 27, and by mid-June, the disease was spreading at an alarming rate. As a new wave of smallpox hit the area and continued to spread, many residents fled to outlying rural settlements. The combination of exodus, quarantine, and outside traders' fears disrupted business in the capital of the Bay Colony for weeks. Guards were stationed at the House of Representatives to keep Bostonians from entering without special permission. The death toll reached 101 in September, and the Selectmen, powerless to stop it, "severely limited the length of time funeral bells could toll." As one response, legislators delegated a thousand pounds from the treasury to help the people who, under these conditions, could no longer support their families.

On June 6, 1721, Mather sent an abstract of reports on inoculation by Timonius and Jacobus Pylarinus to local physicians, urging them to consult about the matter. He received no response. Next, Mather pleaded his case to Dr. Zabdiel Boylston, who tried the procedure on his only son and two slaves&mdash;one grown and one a boy. All recovered in about a week. Boylston inoculated seven more people by mid-July.

The epidemic peaked in October 1721, with 411 deaths; by February 26, 1722, Boston was, once again, free of smallpox. The total number of cases since April 1721 came to 5,889, with 844 deaths&mdash;more than three quarters of all the deaths in Boston during 1721. Meanwhile, Dr. Boylston had inoculated 242 people, with only six resulting in death.

The Inoculation Debate
Boylston and Mather's inoculation crusade "raised an horrid Clamour" amongst the people of Boston. Both Boylston and Mather were "Object[s] of their Fury; their furious Obloquies and Invectives," which Mather acknowledges in his diary. Boston's Selectmen, consulting a doctor who claimed that the practice caused many deaths and only spread the infection, forbade Boylston from performing it again.

The New England Courant published writers who opposed the practice. The editorial stance was that the Boston populace feared that inoculation spread, rather than prevented, the disease; however, some historians, notably H. W. Brands, have argued that this position was a result of editor-in-chief James Franklin's (Benjamin Franklin's brother) contrarian positions.

Public discourse ranged in tone from organized arguments by tobacconist and medical practitioner John Williams, who posited that "several arguments proving that inoculating the smallpox is not contained in the law of Physick, either natural or divine, and therefore unlawful," to more slanderous attacks, such as those put forth in a pamphlet by Dr. William Douglass of Boston entitled The Abuses and Scandals of Some Late Pamphlets in Favour of Inoculation of the Small Pox (1721), on the qualifications of inoculation's proponents. (Douglass was exceptional at the time for holding a medical degree from Europe.) At the extreme, in November 1721, someone hurled a lighted grenade into Cotton Mather's house.

Medical Opposition
Several opponents of smallpox inoculation, among them John Williams, stated that there were only two laws of physick (medicine): sympathy and antipathy. In his estimation, inoculation was neither a sympathy toward a wound or a disease, or an antipathy toward one, but the creation of one. For this reason, its practice violated the natural laws of medicine, transforming health care practitioners into those who harm rather than heal.

As with many colonists, Williams' Puritan beliefs were enmeshed in every aspect of his life, and he used the Bible to state his case. He quoted Matthew 9:12 when Jesus said: "It is not the healthy who need a doctor, but the sick."

In contrast, Dr. William Douglass proposed a more secular argument against inoculation, stressing the importance of reason over passion and urging the public to be pragmatic in their choices. In addition, he demanded that ministers leave the practice of medicine to physicians, and not meddle in areas where they lacked expertise. According to Douglass, smallpox inoculation was "a medical experiment of consequence," one not to be undertaken lightly. He believed that not all learned individuals were qualified to doctor others, and while ministers took on several roles in the early years of the colony, including that of caring for the sick, they were now expected to stay out of state and civil affairs.

Douglass also felt that inoculation caused more deaths than it prevented. The only reason Cotton Mather had success in it, he said, was because Mather had used it on children, who are naturally more resilient. Douglass vowed to always speak out against "the wickedness of spreading infection."

Speak out he did: "The battle between these two prestigious adversaries [Douglass and Mather] lasted far longer than the epidemic itself, and the literature accompanying the controversy was both vast and venomous." In the end, Douglass grew to accept inoculation, but he stood his ground on the need for professional standards.

Puritan Resistance
Puritan principles were core to the religious arguments against inoculation. They believed that they were "elected" by God to establish a godly nation in the Massachusetts Bay Colony. As such, the notion of God’s will being evident in their daily life was paramount, and they strove to accept every affliction as proof of God's special interest in their affairs.

God's authority was absolute, and Williams questioned whether the smallpox "is not one of the strange works of God; and whether inoculation of it be not a fighting with the most High." He also asked his readers if the smallpox epidemic may have been given to them by God as "punishment for sin," and warned that attempting to shield themselves from God's fury (via inoculation), would only serve to "provoke him more." The Puritans found meaning in affliction, and they did not yet know why God was showing them disfavor through smallpox. Not to address their errant ways before attempting a cure could set them back in their "errand."

Many Puritans believed that creating a wound and inserting poison was doing violence and therefore was antithetical to the healing art. They grappled with adhering to the Ten Commandments, with being proper church members and good caring neighbors. The apparent contradiction between harming or murdering a neighbor through inoculation and the Sixth Commandment--"thou shalt not kill"--seemed insoluable and hence stood as one of thee main objections against the procedure.

Williams maintained that because the subject of inoculation could not be found in the Bible, it was not the will of God, and therefore "unlawful." He also explained that inoculation violated The Golden Rule, because if one neighbor voluntarily infected another with disease, he was not doing unto others as he would have done to him. With the Bible as the Puritans’ source for all decision-making, lack of scriptural evidence concerned many, and Williams vocally scorned Rev. Mather for not being able to reference an inoculation edict directly from the Bible.

Inoculation Defended
With the smallpox epidemic catching speed and racking up a staggering death toll, a solution to the crisis was becoming more urgently needed by the day. The use of quarantine and various other efforts, such as balancing the body's humors, did not slow the disease's spread. As news rolled in from town to town and correspondence arrived from overseas, reports of horrific stories of suffering and loss due to smallpox stirred mass panic among the people. "By circa 1700, smallpox had become among the most devastating of epidemic diseases circulating in the Atlantic world."

Cotton Mather strongly challenged the perception that inoculation was against the will of God and argued that the procedure was not outside of Puritan principles. He wrote that "whether a Christian may not employ this Medicine (let the matter of it be what it will) and humbly give Thanks to God’s good Providence in discovering of it to a miserable World; and humbly look up to His Good Providence (as we do in the use of any other Medicine) It may seem strange, that any wise Christian cannot answer it. And how strangely do Men that call themselves Physicians betray their Anatomy, and their Philosophy, as well as their Divinity in their invectives against this Practice?" The Puritan minister began to embrace the sentiment that smallpox was an inevitability for anyone, both the good and the wicked, yet God had provided them with the means to save themselves. Mather reported that, from his view, "none that have used it ever died of the Small Pox, tho at the same time, it were so malignant, that at least half the People died, that were infected With it in the Common way."

The practice of smallpox inoculation was eventually accepted by the general population due to first-hand experiences and personal relationships. Although many were initially wary of the concept, it was because people were able to witness the procedure's consistently positive results, within their own community of ordinary citizens, that it became widely utilized and supported. One important change in the practice after 1721 was regulated quarantine of inoculees.

Inoculation visibly and directly aided man's control of the disease, the level of infection, mortality rates and the spreading of the epidemic. Planned inoculation led to better observation of the body's responses and allowed people the ability to time the onset of the pox and control the disease's intensity. For example, by inoculating in the months of milder climate, one had a better chance of fighting the infection and becoming immune instead of the alternative: natural exposure to the disease during harsher weather, when the body's defenses were already challenged.

Additionally, by the 1750s, innovations and experience with inoculation focused on better insertion of pox fluid and preparation of body to withstand the disease. By controlling the point and time of infection, bodies could be conditioned to optimal state before contracting smallpox, therefore providing a better opportunity to fight and achieve immunity. Dependent upon a person's constitution, by adhering to a specific diet or purging, one could physically handle the infection more successfully. It was also discovered that inoculation produced less scarring and physical defects than a common, naturally contracted case.

The Aftermath
Although Cotton Mather and Dr. Boylston were able to demonstrate the efficacy of the practice, the debate over inoculation would continue even beyond the epidemic of 1721-22. After overcoming considerable difficulty and achieving notable success, Boylston traveled to London in 1724 where he published his results and was elected to the Royal Society in 1726.

The responses of the Boston clergymen to the reproaches put forth by the anti-inoculation camp highlighted seminal changes the Puritan church was undergoing at the time. By prescribing recent advances in medicine, the Boston ministers modified the doctrine of theological pathogenesis in an attempt to maintain the old order according to which it was the clergy’s duty and privilege to interpret illnesses and their cures. However, the contradiction of simultaneously upholding tradition and embracing innovations was impossible to resolve and, as a consequence, the clergy continued to lose influence over secular affairs in eighteenth-century New England.

In the end, because of inoculation, lives were saved and the epidemic ceased to exist. Even today, the procedure is attributed with ending the devastation caused by the early epidemics and the act of vaccination, in many ways an updated and modernized form of the procedure, is recommended by the Centers for Disease Control for at-risk populations, such as potential victims of bioterrorism and research scientists who continue to work with strains of the disease.