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Pox Americana

A Baltimore Doctor, an Envelope Full of Scabs, and a National Scandal Over Smallpox Vaccination in the 1820s

Dr. Edward Jenner published a famous treatise suggesting that deliberate infection with cowpox might give an individual immunity from smallpox.

By W.E. Earle | Posted 2/5/2003

The federal government's reintroduction of smallpox vaccination has not yet reached Baltimore. When it does, one hopes it works out better than Washington's first foray into vaccination--when a Baltimore doctor's leadership of the national effort led to a tragic epidemic in North Carolina, the doctor's humiliation, and the federal government's abandonment for decades of any role in protecting the public health.

One day in 1819, Dr. James Smith escorted his five children into the Baltimore house of a dying smallpox patient. The victim's face and body were disfigured by pus-filled blisters--the characteristic "pocks" of smallpox--and the highly communicable disease was at the peak of contagiousness. All the children were close enough, Smith wrote in a January 1822 letter to the Baltimore-based national newsweekly publication Niles' Weekly Register, "to breathe the natural contagion which filled [the air] to a highly offensive degree."

During the visit, Smith lanced "the fullest pustules which were on the face of the diseased person" to extract pus and bits of scab. Then he deliberately worked the extracted material into small cuts in his children's arms. They left the house only when Smith was certain that all the children had been exposed to enough of the dreaded smallpox virus to kill most children.

But not Smith's children--and that was the point of his chilling demonstration. As the leading advocate in Baltimore and the nation of vaccination against smallpox, Smith believed that his vaccinated children could resist even the most extreme exposure.

And he was right: The children survived, and Smith's faith in himself and his technique was vindicated. On other occasions he would not be so lucky.

Smith's dramatic demonstration in 1819 had its roots in England in 1798. It was then that Dr. Edward Jenner published his famous treatise suggesting that deliberate infection with cowpox might give an individual immunity from smallpox.

If this were true, it would have been a monumental discovery. Smallpox had been a scourge for centuries, a loathsome, dreaded disease that stuck down whole communities and left its victims dead, blind, or mutilated with scars. Cowpox, by contrast, was relatively mild. Its symptoms soon passed. Remnants of pocks--circular skin eruptions--might remain, but they were generally insignificant.

Some doubted Jenner, and some early attempts to duplicate his results failed. However, Jenner was actually right, and, gradually, more and more doctors accepted his theory.

One of Jenner's earliest American converts was James Smith, a young Baltimore doctor. His first vaccination, performed on 7-year-old Baltimore almshouse resident Nancy Malcum in May 1801, according to Joel N. Shurkin's 1979 book The Invisible Fire: The Story of Mankind's Victory Over the Ancient Scourge of Smallpox, was clearly successful, and it made the American a true believer. By 1802 he had established a "vaccine institution" in Baltimore to provide reliable cowpox material for inoculations. By 1803 he was so committed to the cause that he named his firstborn son Edward Jenner Smith.

Young Dr. Smith was already well-known to the Baltimore medical community--but not necessarily well-liked. He had received city appointments to public-health positions but had also clashed with city authorities and the medical establishment when they attempted to suppress news about epidemics. The strong-willed, opinionated doctor had supporters among local doctors, but he had detractors as well, and those detractors would one day cost Smith dearly.

Smith's vaccine institution used an "arm-to-arm" system for producing vaccine. Cowpox scratched into the skin of a patient produced a lesion from which new infectious material could be drawn several days later. That material was then scratched into the skin of a new patient, who would provide vaccine for the next patient, and so on. Smith kept his arm-to-arm system running for some 20 years.

The system also generated surplus quantities of infectious material for distribution elsewhere. Many Baltimore doctors drew vaccine from Smith, and supplies could be sent to distant parts by mail since the material remained biologically active for several months.

The institution was bedeviled by one recurring problem: how to pay for it? Smith and other doctors occasionally received municipal or state subsidies, but funding was intermittent at best, and doctors frequently performed vaccinations for free. In 1811, for example, during a Baltimore epidemic, the Niles' Weekly Register urged citizens to seek the vaccinations "performed gratis at the dispensary, at the 'Vaccine Institution,' and by almost every physician in the city."

Smith himself was uniquely affected by the funding problem. His institution was, in effect, a public-health enterprise, and he could hardly turn patients away for want of funds. Consequently, in 1809, he arranged to have himself designated state vaccine agent. Financially, however, the honor was hollow: Legislators appropriated no funds. Instead, they authorized a lottery. Smith could sell tickets, cover prizes and costs from the proceeds, and support his institution with whatever was left. It helped, but Smith wasn't satisfied.

In 1813, he approached Congress. He accomplished his immediate goal--he was designated the national vaccine agent--but the honor again was honorary: no salary, no appropriation. Smith only got free postage for his work. He returned to Congress several times with plans for a revised national institution that Congress would actually pay for, but Congress never obliged him.

Still, Smith built quite an enterprise on fees and donations. At one point he had 20 agents spreading the gospel of vaccination, and he was the major source of smallpox vaccine south of New England. He also spoke in defense of vaccination whenever the skeptical raised questions: His 1819 demonstration on his children was only one of his efforts to combat the nonbelievers.

Smith's supporters would later say that he saved tens of thousands of lives, and there's no doubt that he did. In the fall of 1821, however, it all began to fall apart.

Smith occasionally gathered samples from smallpox victims, and he had a packet of scabs in his office one day while he was packaging vaccine material to ship to correspondent doctors. The scabs were in a folded paper on which Smith "had written carefully, to avoid accidents, that it contained the variolous or small pox matter," according to a letter he wrote to Congress which was reprinted in Niles' in 1822. Subsequently, however, "this paper was mislaid, and, after searching for it in vain, I had concluded . . . it might have been swept out of my office with other waste papers."

But it hadn't. Smith had inadvertently mailed it to Dr. John Ward in Tarboro, N.C. By December the agitated Ward was writing Smith to tell him that the "vaccine" Smith had sent him had left Ward's patients sick or dying. Ward faced an epidemic: Before it ended, some 60 people around Tarboro were sick, and 10 had died.

When Smith first learned of the North Carolina epidemic, he sought some innocent explanation. Perhaps it was not smallpox. Perhaps it was "varioloid disease," which resembled smallpox.

No, replied Ward emphatically, it was genuine smallpox. Furthermore, Ward described to Smith the parcel he had received--with "variolous" written on it. That was conclusive, even to Smith: What Ward had received was not vaccine material, but the missing packet of smallpox scabs.

Smith was so appalled at what he had done that he couldn't help but attempt to spread the blame. He claimed that the "variolous" notation should have told Ward what the parcel contained. Perhaps Ward was too ill-trained to recognize the Latin name for smallpox, or to distinguish smallpox from cowpox scabs. Ward angrily rejected Smith's parceling out blame in his direction. Furthermore, the fact remained that the whole deadly tragedy sprang from Smith's carelessness: If Smith hadn't blundered, nothing that Ward might have done would have been necessary.

The matter might have ended there--a tragedy for the victims and an unresolved dispute between two doctors, with the mortifying publicity limited to North Carolina--but for Smith's initiative in establishing the national vaccine agency. That made him at least nominally a federal official--and vulnerable to a congressional investigation that would spread the whole sorry story nationwide.

On Jan, 31, 1822, U.S. Rep. Hutchins G. Burton of North Carolina moved that the House consider repealing the 1813 act authorizing the national vaccine agency. Initially, the motion led only to a committee report that Smith might have helped write. The report noted "with pain and regret, the occurrences which have lately transpired in the state of North Carolina." It also noted Smith's acknowledgement "that it was the genuine small pox matter he had sent to North Carolina, through his own mistake." However, the committee believed "that proper attention will overcome every obstacle of that kind." They declined to recommend any change in the law.

On March 28, however, Congressman Burton renewed his attack. The vaccine agency was "a mere nuisance, of the most dangerous kind," and congressional inaction would mean "suffering, under the authority of our laws, hundreds to be slaughtered with indifference," he told Congress, according to Niles'. Supporters of Smith and of vaccination could not resist a passionate colleague pursuing an issue that had uniquely stricken his own district, and Burton got a second committee examination of the scandal.

The second committee report was a disaster for Smith. A national vaccine agency, it insisted, was a repugnant monopoly inevitably tainted by greed. Such a role, vested in one man, would enable him "to accumulate wealth, by levying contributions from all parts of the union," according to Niles'. Fulfilling national vaccine requirements would inevitably lead the agent "to the necessity, of either relinquishing the proferred fee, or of transmitting matter of doubtful character." Necessary subagents could be "[c]areless or incompetent assistants, guided more by cupidity than intelligence" who might "be instrumental in producing mischief, by the distribution of inert matter, or by the more fatal error of disseminating a pestilence instead of a prophylactic."

None of this reflected what had actually happened in North Carolina. However, it was a plausible explanation of how the tragedy might have occurred--assuming financial motives had played any role. It didn't matter that they hadn't. Thus, it was argued, the law should be repealed, the agency disbanded, and the whole matter left to local authorities.

Unfortunately, Burton wasn't the only one raising questions about Smith's motives. Just as the North Carolina catastrophe was unfolding, smallpox hit Baltimore. In fact, Baltimore was suffering more smallpox deaths per week than died during the entire Tarboro tragedy.

The epidemic raised questions. In March, 1822, Niles' Register asked, "How happens it that the small pox prevails here--'the head quarters of vaccination?'" The answer, suggested the Register, was precisely "because Baltimore is the head quarters of vaccination. The act of congress to encourage vaccination, has rather, in our opinion, tended to encourage small pox, by making a matter of individual profit out of what had better been left to the general care of medical gentlemen. . . . There is something wrong or rotten in this business."

Some local physicians sounded the same note when Smith sought their support. While some Baltimore doctors praised Smith for providing them for years with free vaccine, Shurkin's Invisible Fire quotes others asked pointedly, "What motives can prompt Dr. Smith to hang about small-pox patients like a preying vulture?"

The cause was hopeless. Smith was fired even before Congress finished repealing the vaccine-agency law. Local authorities could fill the void if they wanted, but Congress itself would not attempt another major public-health measure for decades to come.

Smith petitioned Congress several times in subsequent years. He claimed to have discovered indications that the Tarboro tragedy may have involved malevolent forces plotting against him. His petitions were heard politely but accomplished nothing. His efforts to revive the agency, and to regain his position, were futile.

In 1824, Smith appeared publicly with a committee welcoming the Marquis de Lafayette to Baltimore. Characteristically, he presented the Frenchman with a valuable gift: a vial of smallpox vaccine. Shortly thereafter, however, the defeated Smith abandoned his long public advocacy. He apparently pursued an ordinary medical practice for nearly two decades before dying in Pikesville in 1841. He was doubtless disillusioned by his failures, if not embittered.

Nevertheless, some historians have been kind to Dr. Smith. The Medical Annals of Baltimore makes a good case that it was Smith, more than any other, who established vaccination in the United States. The Medical Annals of Maryland are even more emphatic, stating flatly that "his services entitle him to be called 'The Jenner of America.'"

And if Smith were living today? Would he be discouraged the defeat of the scourge he battled might not have proven a final victory? Or would he find some grim satisfaction in knowing that the federal government he tried to enlist in the cause was finally taking the responsibility he tried to assign it 180 years ago?

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