Transcript of a paper read at the Department of Social Studies of Medicine, McGill University, January 20, 2016.
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Edward Jenner needs little
introduction, at least in terms of his international repute. The ‘father of
immunology’ is credited – usually – with the discovery of the cowpox vaccine in
1796 and, more importantly, with its propagation. Smallpox was, after a
concerted global effort by the WHO, eliminated in 1979. Jenner is typically considered to be the progenitor of a
process that took almost two centuries. He is the conqueror of smallpox,
saviour of millions of lives. Such is the hero narrative that I remember
learning in school, aged 9, and which still gets trotted out every year for
kids of a similar age, at least in the UK.
For those with a more involved awareness of the history
of vaccination there is another standard narrative, centring at first on the
disputed claims at discovery of the vaccine and the ways in which colloquial
knowledge coalesces and gains momentum, becoming formal knowledge through
professional appropriation. What follows is a Kuhnian explanation of the rise
of the vaccine, with a crisis among the medical establishment (whose fortunes
depended on the forerunner of vaccination – inoculation with actual smallpox),
followed by the fairly rapid acceptance of the vaccine as various studies and
surveys seemed to prove its efficacy, and as prominent personages lent it
support. Key moments tend to get mentioned as guarantors of this medical
revolution – the adoption of vaccination by Napoleon for his military forces;
the world voyage of Francis Xavier Balmis, successfully introducing vaccination
to the entire Spanish Empire as well as to China by 1806; the orders of the
King of Denmark to vaccinate soldiers, their families, sailors, students and
the poor free of charge; and in Jenner’s homeland, two parliamentary grants
acknowledging his discovery, amounting to £30,000, the second of which, in 1807,
coming after a laudatory report on the practice by the Royal College of
Physicians. Each of these signs of success stands for empirical proof of the
medical efficacy of vaccination. By a slightly more complex route, Edward
Jenner is again enthroned as a humanitarian and medical hero.
I want to disrupt this Kuhnian narrative and complicate
it. The first observation is that, on Jenner’s death in 1823, the practice of
vaccination, at least in England, seemed in fact to be waning. Jenner’s last
days were spent still ardently trying to get the message out about his particular method of vaccination, as the
only efficacious means of performing the procedure. He went to his grave
ambivalent about his own reputation – yes there had been successes, but by no
means was the vaccine revolution complete, and especially not in his own
country. I will spend some time analysing Jenner’s own efforts to try to bring
about his revolution, showing that discourse within the medical establishment
often had precious little to do with the efficacy of vaccination strictly in
terms of medical outcomes. Vaccine debates pivoted around issues of fear, moral
panic and trust, with trust in Jenner himself being a key marker of continued
uncertainty about the practice of vaccination. Jenner’s personality and his own
actions in the formative years of vaccination often get neglected in the
success story of the vaccine, but his character and his politicking are
extremely important influences in what turns out to be a very messy beginning.
The tenor of the medical exchanges over vaccination are
doubly important because of the public nature of the vaccine controversy. In
significant ways, medical debate was publicly performed to an enormous audience for whom smallpox remained a real
and ever-present danger to life. The traditional markers of vaccine success
that I just listed didn’t necessarily affect the public mood in a positive way,
and indeed I would argue that the difficult first few decades of vaccination
were defined by the rhetorical failures of those in favour of the vaccine
effectively to influence a prevalent atmosphere of fear and mistrust. This
second line of argument takes me beyond Jenner’s death to the broader
anti-vaccination movement of the nineteenth century, and the ways in which fear
tends to trump fact in public discourse.
The disruption
is necessary because the standard narrative does not explain why Jenner was, by
the middle of the nineteenth century, almost an anti-hero, championed by the
medical establishment, but despised by many public-opinion makers and by much
of the public at large. Jenner was memorialised by a statue in Trafalgar Square
in the late 1850s, thanks largely to funds from the USA and from Russia, but
after only fours years he was removed and stored out of the way in Kensington
Gardens. One of those who argued for his removal in Parliament noted that
Jenner had no place ‘among statues of our naval and military heroes’, for not
only were medical innovations themselves not the stuff of heroes, but Jenner’s
particular innovations were considered to be dubious at best. Sixty years after
Jenner had published his Inquiry into the
Causes and Effects of the Variolae Vaccinae, he was denounced in the House of Commons as the
‘promulgator of cow-pock nonsense’.
At the same time, and
paradoxically, vaccination was made compulsory for all newborn children in
Britain, with failure to comply punishable by fine and imprisonment for the
parents. The first government intervention in public health with the threat of
penal action came at a time when the public mood was decisively anti-Jennerian.
Despite rafts of testimony from physicians around the world in favour of
vaccination – demonstrating that the paradigm had indeed shifted from smallpox inoculation
to vaccination among the medical community – the public remained unconvinced
and afraid. Whole towns revolted against the vaccination laws, and smallpox
still frequently reached epidemic proportions across England, killing thousands
through the 1870s and 1880s. It seems to make sense, then, to emplot the story
of Jenner and the politics of vaccination, at least in Britain, as one of
failure, if considered from the point of view of public reception and
compliance.
Edward Jenner’s certainty that
vaccination safely and effectively immunised against smallpox was based, in the
first instance, on limited empirical testing and, later, on deeply held belief.
In his lifetime neither he nor anyone else could explain why vaccination worked. Indeed, the reason for the efficacy of vaccination
remained mysterious throughout the nineteenth century. This fundamental gap in
knowledge allowed for the creation of myths on both sides of the vaccine debate.
Jenner himself was the progenitor of a number of vaccine myths that ultimately
hurt his cause. What began as postulation ended up as part of the dogma of
Jennerian vaccination.
The first piece of dogma was that cowpox in turn came
from a disease in horses’ heels called ‘grease’, and that the effectiveness of
the vaccine lay in the common animal origins of both cowpox and smallpox.
Smallpox was, as far as Jenner was concerned, a result of the close and
unnatural interactions of humans with animals, and could only be cured –
uncannily enough – by other matter taken from an animal. Jenner’s key
achievement lay in taking matter from a cowpox pustule on the arm of Sarah
Nelmes and then inoculating James Phipps with it, and thereafter testing James for
immunity against smallpox by trying, repeatedly, to give him the disease. Nothing
in this depended on establishing an origin for the cowpox in horse grease. Yet
Jenner insisted on it. By the time he realised that there was no connection
whatever, this error was used frequently as a stick with which to beat him.
Jenner’s opening salvo in the establishment of vaccination contained an error
sufficient to establish doubt in his reasoning, his methods and his reputation.
The second piece of dogma was that vaccination was good
for life. Once administered to a child, the cowpox afforded unlimited
protection against smallpox. This was Jenner’s greatest assumption. He had no
way of knowing that it could be true, but he was absolutely convinced that it
was, and he held onto this belief for the rest of his life. Increasing numbers
of cases of adult smallpox in those who had been vaccinated as children were
used by opponents of vaccination to point out that vaccination did not work at all. A second element of doubt was
therefore also original to Jenner’s publication of his vaccine success, calling
into question Jenner’s trustworthiness and his motives.
Both of these errors might perhaps have been
inconsequential had the debate about vaccination taken place out of the public
eye, among the medical establishment, and if the motive of those involved had
been the elimination of smallpox. But from the very first the debate had been
in the public and, importantly, for
the public. Jenner had self-published his Inquiry,
avoiding the painstaking processes of the Transactions
of the Royal Society, in the interests of getting the discovery into as many
hands as possible. This is often interpreted as a sign of Jenner’s humanitarian
spirit, literally giving away what could have been a lucrative and proprietary
method. I think Jenner had other ambitions, beyond the mere accumulation of
wealth. Jenner was outside of the establishment medical circles in London, a
city he hated, and saw an opportunity for fame without having to sacrifice his
bucolic repose. As it turned out, that did not work, but in any case Jenner did
not enamour himself to those who might have championed his cause. He did not
think it necessary to hold any medical credentials to perform vaccination, so
long as his precise instructions were followed. This, at one stroke, annoyed
the medical community at large, especially those whose livelihoods depended on
charging high fees for elaborate rituals of smallpox inoculation, and
identified the practice of vaccination with Jenner himself. He was not merely the
discoverer of a biomedical miracle, but the architect of the precise delivery
system of that miracle, sending vaccine matter through the post to whoever
wanted it, along with instructions.
The public announcement of the discovery resulted in it
being publicly maligned. If there was a crisis of medical knowledge in the
first few years of the nineteenth century, it took the form of the whipping up
of public fear and moral panic, with the response on the vaccine side being an
equal storm of fear mongering about the dangers of traditional variolation
combined with some extraordinary gutter-press character assassinations. Worst
of all, those who might have been Jenner’s allies in the establishment of his
reputation soon turned out to be the biggest threat to it. Dr William Woodville
of the London Smallpox and Inoculation Hospital, together with a budding fan of
Jenner’s Inquiry, George Pearson,
found a source of cowpox within London and set out to test it at the Smallpox Hospital. The cowpox was
almost immediately cross-contaminated with smallpox and the results were at
variance with what Jenner had seen. Nevertheless, seeing a chance for fame,
Woodville and Pearson broadcast their success and subsequently sent threads
dipped in smallpox matter across the country and to Europe, claiming to be
distributing the cowpox vaccine. They were likely the direct cause of a
smallpox epidemic in Geneva. It was an extraordinary blunder that caused a
personal rift between Jenner and Pearson that would endure until Jenner’s
death.
Jenner wrote to Pearson that their names could not be
entangled in the practice of vaccination. If, Jenner said, ‘vaccine
inoculation, from unguarded conduct, should sink into disrepute… I alone must
bear the odium’. This was as early as 1802. Already by that date Jenner had
bound his reputation to the practice and it was the safeguarding of his
reputation, rather than the spread of vaccination per se, that seemed to
motivate him the most. Those who saw in Jenner’s success the potential to lose
out did their best to destroy that reputation, challenging both Jenner’s
innovation in the first place, and the efficacy of vaccination per se.
 |
| Less well-known piece by Charles Williams, 1802, showing a horned and tailed Jenner feeding children into the mouth of a pestilent beast, which excretes them as monstrous waste. The knights of truth in anti-vaccinism muster on the horizon. |
The prominent physician
Benjamin Moseley was the culprit in chief, responding to the
‘Cowmania’ in 1800 with a series of concerns. While Jenner had styled
cowpox Variolae Vaccinae, smallpox of the cow, Moseley called
it Lues Bovilla, bovine syphilis, with all the long-term mental and
nervous consequences of the human ‘pox’. He asked:
Can any person say what may be the
consequence of introducing the Lues Bovilla, a bestial humour
– into the human frame, after a long lapse of years? Who knows, besides, what
ideas may rise in the course of time, from a brutal fever
having excited its incongruous impressions on the brain? Who knows, also, but
that the human character may undergo strange mutations from quadrupedan
sympathy and that some modern Pasiphaë may rival the fables of old?
His classical reference might pass us by, but the invocation
of bestiality would have been obvious to the educated in 1800. Pasiphaë, cursed
by Poseidon, had copulated with a bull. Having built a wooden cow and covered
it with cowhide, she had hidden inside it in order to receive her desired mate.
She later gave birth to the Minotaur. Moseley played not only on the taint of
venereal disease, but also on the fragility and sanctity of the human, warning
of a hybrid and brutal progeny. Vaccination was not only dangerous, it was
immoral. Jenner’s name was singularly attached to the spread of this
immorality.
This is the
background to the famous Gillray image, which is familiar to many but often misunderstood. Jenner stands centrally,
penetrating the arm of a terrified patient with ‘vaccine pock, hot from ye
cow’. The patient has previously been ‘opened’ by a special brew. To the right,
those already vaccinated undergo a series of horrors caused by contamination
with animal disease. The image is shot through with innuendo about sexual
transgression (communing with the beast) and venereal disease (syphilis). The
pregnant hag on the extreme right seems at once to vomit and give birth to
bovine progeny, while behind her another matron sprouts the satyr-like horns of
the beast. The breeches of a bumpkin are breached. The faces of others are
marked by monstrous eruptions of ‘the pox’.
Jenner
didn’t respond to the satire. The general impression we have of Jenner is that
given to us by his friend and biographer, John Baron, who styled Jenner as
high-minded, a tool of providence, immune to whatever nonsense was spoken in
the gutter. By no means would he stoop so low as to engage the trash talkers.
This wasn’t true, but it’s been repeated so often it has become orthodox. The
problem for Jenner was that, after Moseley’s nonsensical allusions to the
coming of a modern minotaur and Gillray’s visualisation of it, another of
Jenner’s opponents went out of his way to show it was real. In 1805 Dr Rowley,
who derived his living from the impugned technique of inoculating with
smallpox, claimed to have found it and to have showed it to Moseley. Moseley
marked the animalistic transformation and
Rowley published exaggerated portraits of Gillray-esque figures, supposedly
drawn from life. The ‘Ox-faced boy’ and the ‘Mange girl’ were presented as tangible proof of the brutal result of
bestial infection, in a pamphlet titled Cow-Pox
Inoculation No Security Against Small-Pox Infection.
Jenner
scholars have long known that Jenner penned a reply, because Baron saw it and
mentioned it in his biography. But Baron denied that it was ever published,
presumably to safeguard Jenner’s reputation. A ‘serious reply to such
disgusting observations as characterised their [the anti-vaccinist] productions
would indeed have been quite unworthy’ of Jenner, Baron wrote. However, he knew
that Jenner valued ridicule as ‘a weapon that might be fairly and effectually
wielded’. Jenner’s manuscript was styled, according to Baron, as a ‘letter to one
of the chief anti-vaccinists’, filled with ‘genuine wit and polished irony’.
Jenner clearly thought it worthy of a public airing. A letter survives that
clearly indicates the existence of a substantial manuscript, too long for
quarto form, which Jenner sent to an unscrupulous agent called Dibdin. Jenner
demanded complete secrecy in employing Dibdin to find a publisher. The
pamphlet Letters to Dr Rowley appeared
in 1805, in octavo form, published by H.D. Symonds (a publisher regularly
favoured by Jenner’s allies).
I
have pieced together the evidence to the point that I can confidently attribute
this pamphlet to Jenner. Under the veil of anonymity, Jenner poured scorn on
his critics and tarnished them with ‘proof of insupportable vanity and
self-conceit’. Jenner compares their argumentation to the ramblings of an old
woman, who appears in this pamphlet, purchasing a copy of Gillray’s print. But
though it poked fun at the arguments of vaccination’s detractors, it did not
positively do much good for the cause of vaccination itself. A prior concern
was Jenner’s good name, which he was highly motivated to uphold, and
purposefully active in so doing by means that cut across the grain of the image
of himself he wished to portray – that of a gentleman in repose, above the
clamour.
Further
evidence of this is to be found in the management of the institutions
established to further the cause of vaccination in his name. But whereas his
anonymous pamphleteering was a dirty fight in the yellow press, his
institutional tactics involved the societal elite. George Pearson, the man who
spoiled the broth at the Smallpox Hospital, quickly tried to grab the momentum
and establish the first vaccine institution, which Jenner immediately moved to
destroy. He was able to do this through the connections he had made after the
publication of his Inquiry, which had
even gained him an entrée at Court and an audience with the King, and through
his petitioning for his first Parliamentary grant. Pearson had canvassed
opinion to try to prevent Jenner receiving that money – £10,000 in 1802 – but failed. Jenner had been
acclaimed as the discoverer of the vaccine by the highest authority, and he
planned to use this renown to capitalise on his advantage. His first move was
to seek an audience with the Duke of York, who had offered patronage to
Pearson’s institution, and demand that he withdraw it. The Duke of York did so,
offering it to Jenner instead. The whiff of dishonour that attached to Pearson
in losing the support of such an eminent sponsor caused all those interested in
vaccination – public figures and the medical establishment – to come to
Jenner’s cause. The Jennerian Society, which in short order became the Royal
Jennerian Society, was established in 1803.
The point of the
Society was to promote vaccination across the globe, to provide the
instructions and means to vaccinate, wherever it was called for, and to offer
free vaccination at various stations around London. It should have been the
institutional guarantor of Jenner’s success, but its short existence was mired
by personal grievances, inside and outside the institution, and Jenner’s
increasingly personal response to even the slightest deviations from his word
and lore. Jenner was, typically, absent from London and managing by
correspondence, leaving the institution to rot from the inside. The everyday
rancour of the Society is evidence of the ways in which banalities get in the
way of, or even take precedence over, medical practice. The chief vaccinator of
the Society, John Walker, was involved in a number of disputes, being accused
by the secretary of breaking the seals on his mail, while in turn accusing the
secretary of abusing his mail-franking privileges. Walker was heavily censured
by Jenner, who then sought ways to remove him. Walker, vaccinating on a daily
basis, found it practical to deviate slightly from Jenner’s iron-clad rules
about when lymph could be taken from the cowpox pustule on the arm, for insertion
into the arm of another. Walker’s mistake was to publish this account, thinking
that the how of vaccination was still
in development. Jenner was enraged. He wrote to the committee complaining
bitterly of Walker’s incompetence and, even though Walker’s own opinions on
vaccination had hardly been noticed in public, said that the society had been
‘disgraced’. Claiming that he, Jenner, would be held responsible for Walker’s
conduct, he threatened to resign from the Society unless Walker was immediately
sacked. There were protests, held in open-court sessions of the Society, and
the whole affair was a public disaster. Walker, not without support, was
ousted. He immediately set up his own vaccine institution, next door to Jenner’s, and then stood on the street diverting
parents and children into his own premises. Jenner immediately instructed the
Society to write and rally MPs, peers, bishops and other
clergy to his side, again wielding power in the form of patronage. But even
though he could, for a while, call on an influential army, the taint of scandal
and impetuousness was wearing. The Society was running out of money and was
wound up. A new National Vaccine Establishment was on the horizon, with
government backing. Jenner thought it should be his crowning glory, but it was
his worst humiliation.
For more than five months of 1808,
Jenner was detained in London, hating every minute. Paranoid about his personal
safety, he felt isolated from friends, exposed to enemies and inadequate to the
task in hand, namely, in his words, ‘to erect a state Pillar, without any
knowledge of such kind of Architecture’. He described his heart and spirit as
being ‘broken from the cruel privations of London’ and saw ‘by the most
abominable falsities’ the ‘ruin of [his] private character’. The role that he
had carved out for himself of being chief consultant on the organisation and
procedures of the new Establishment were suddenly perceived as ‘the galling
fetters which the Public have forged’ for him. When eventually the
Establishment came into being, Jenner was named Director, but he felt himself
to be the ‘Director directed’. Out of eight names he put forward to fill the
principal vaccinating stations, all but two were rejected. Of those who were
named, one was associated with George Pearson, and Jenner felt that to be a
despicable insult. In my estimation it was no longer the status of vaccination
that was on the line, but the perceived honour of Edward Jenner. He wrote a
friend:
what
am I but an underling in an Institution in which Pearson will, thro his agents
virtually take the lead; and to resist & thereby gain my point, will throw
me upon a bed of Vipers; for not only those who by a struggle on my part may be
dismiss’d, but their numerous adherents, will be forever wounding me with their
Fangs.
He resigned
immediately, having found no sympathy among exasperated friends. His prognosis
was as follows:
I
am to be torn limb from limb it seems by Government & the College of Phys:
but I hope my Executors will collect my scatterd remains and give me Christian
burial. Hostilities are about to commence, & the odds against me would be
fearful if my Heart was not well shielded – but I have nothing to reproach
myself with, tho much to be vext at… the new Institution is disgraceful to the
Nation & degrading to me.
Actually, with Jenner out of the way, the National Vaccine
Establishment fared reasonably well. But while the Board was quite pleased to
have vaccinated just over 3,000 in 1811, and to have distributed vaccine lymph
to nearly 24,000 across the country and beyond, these numbers remained a drop
in the ocean considering both the population size and the fact that smallpox
inoculation was still ongoing. In that year, a non-epidemic year, 751 deaths
from smallpox were recorded in the London Bills of Mortality. Despite the best
efforts of the Vaccine Establishment and of Jenner, smallpox inoculation
remained a common practice, in competition with vaccination, and was not
outlawed until 1840, after a three-year epidemic that claimed 6,400 lives in
London. Yet vaccination still carried the taint of mistrust and moral
uncertainty. It took another 13 years after the prohibition of smallpox
inoculation to establish compulsory vaccination. By this point, although the
medical establishment had secured a firm footing in government, Jenner’s stock
was at a national low. Compulsion, which came with ever more stringent
enforcement, was nevertheless resisted. The epidemic of 1871-2 claimed 50,000
lives in Britain and Ireland, part of a five-year pandemic across Europe that
claimed half a million lives.
The virulent
strain of anti-vaccinism, supported by such luminaries as Alfred Russel
Wallace, made frequent use of Jenner’s founding mistakes to point out the
ineffectiveness of vaccination.
Jenner had been mistaken about what cowpox was, and who yet could say exactly
how vaccination was supposed to work? Wallace even went so far as to say that
the fear of vaccination was actually causing smallpox. Moreover, it had become
abundantly clear that re-vaccination was required for lifelong immunity, but
after decades of denial from the medical establishment, based largely on
Jenner’s absolute conviction that such an admission would kill the vaccine
movement, this was an extremely hard sell. Throughout the 1880s, whole towns –
most notably Leicester – remained in open defiance of the vaccination laws,
with the complicity of local Guardians. The fear and moral panic that had been
original to Jenner’s early fame was ever present in the public discourse about
vaccination in the last quarter of the nineteenth century. Vaccination caused
syphilis or other diseases; vaccination killed or maimed children; vaccination
was animal taint or impure. After compulsion was introduced, vaccination was an
infringement of liberty and parental authority, un-English, and a portent of
government that would not scruple to meddle in private lives. Kernels of doubt,
about the stuff of the vaccine and about the people who administered it, were
swelled into bushels of fear. Such fear was impervious to reasoned argument,
precisely because those arguments came from mistrusted sources. In short, the
idiom and structure of fear with which we still contend was created in the
first two generations of vaccination, and was associated directly with Jenner
himself.
This stuff has been written about, but the primary assumption is that Edward Jenner
successfully introduced vaccination into the world and that government compulsion
was a necessary step for the sake of public health, perhaps the first step on
the road to social medicine. Within that context of an overarching success
story, some have pointed out the extent to which liberties were trampled and
rights overlooked by heavy-handed government, directed from within the Board of
Health and the Privy Council. I rather think that it is easier to understand
the introduction of compulsory vaccination from the standpoint of failure, in
the context of the ‘promulgator of cow-pock nonsense’ having his statue removed
from the Pantheon of heroes. Uptake of the procedure had been slow, and even
the threat of repeated fines and imprisonment, sometimes with hard labour,
couldn’t persuade some to hand their children over to the man with the lancet. Jenner,
in his lifetime, had persuaded the medical establishment of the effectiveness
of vaccination, and the large majority of physicians subscribed to it
throughout the nineteenth century. But from day one, vaccination was a public
concern, and from day one, the anti-vaccinists had had the better of the public
discourse. The whipping up of fear and moral panic was far easier to manage and
perpetuate than the rival cause of persuading the public of the efficacy of the
new procedure. Jenner, in his time, was mired in concerns with
institutionalising his own reputation, his honour, and his fame, perhaps
thinking that in securing these he would secure the fate of vaccination. In the
short term, at least, he failed in both. Removed from the institution of
vaccination just as it gained government backing, Jenner’s attempts to control
the message, procedures and personnel of vaccination had pretty much come to
nothing, at least at home. The smallpox success story, in fact, is a
twentieth-century story. We can still make Edward Jenner the hero of that
story, if you like, but in that case the story probably needs a new plot.
Credits: Images 1-3, Amazon.com; 4-10, Wellcome Library, London; 11, Archive.org
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