Edward Jenner: Soloist or member of a trio?
The early years
Copyright A R Rees, 2015, Photograph taken courtesy of Dr Jenner’s House, Museum and Garden.
This month it is 266 years since the birth of one of the most celebrated names in medical discovery. Edward Jenner, credited with the discovery of vaccination against smallpox, was born on May 17th 1749 (May 6th by the Julian calendar, still in use in England by a quirk of anti-papal authoritarianism until 1752) in the village of Berkeley in Gloucestershire, England. He went to school in Wotton-under Edge and Cirencester and between the ages of 13 and 21 studied surgery as an apprentice in Chipping Sodbury under the surgeon apothecary Daniel Ludlow and later the country surgeon, George Hardwicke. He then took a position at St George’s Hospital in London under the wing of the well-known ‘scientific surgeon’, John Hunter. In 1772 Jenner returned home to Berkeley where he became practitioner and surgeon to the local community.
He was only 23 years of age but had amassed 9 years of knowledge and experience in dissection and investigation, an extraordinary erudition for one so young. Jenner’s interest in the smallpox disease may have been sparked during his earlier apprenticeship with Ludlow and Hardwicke where it is said (not everyone agrees) that he came across the dairy maid folklore ‘If I am exposed to and succumb to cowpox I will never get smallpox’. A well-known 17th century nursery rhyme, combined with some poetical exegesis, supports perhaps this folklore assertion “Where are you going to my pretty maid? I’m going a milking sir, she said… What is your fortune my pretty maid? My face is my fortune sir, she said”.1
Smallpox and its treatment
During the 18th century smallpox claimed around 400,000 lives per year in Europe. Of the survivors a third became blind. Although the method of variolation (Lat. varius = spotted or stained), in which fluid from a live smallpox sore was injected into individuals subcutaneously, had been known for some 100’s of years its adoption in Europe only began after a series of procedures had been carried out initially on members of the English aristocracy and then in a more controlled set of trials on Newgate prisoners and later orphaned children, with some success. By 1757 Jenner, now 8 years of age, became a beneficiary along with thousands of other English schoolboys of the vastly superior ‘Suttonian’ method of smallpox ‘inoculation’, developed by a Suffolk surgeon Robert Sutton and later improved by his son Daniel. In this procedure a shallow stab with a lancet dipped in smallpox matter was made, penetrating only about a millimeter or so into the skin. This reduced the severity of post-inoculation symptoms but conferred immunity as effectively as earlier procedures and, despite clear cut differences in the morbidity statistics on natural exposure to smallpox (anything from 1-15% of those infected) and the Suttons’ inoculation exposure (perhaps lower than one in a thousand), the widely practiced Sutton procedures were not published until 1796.2
Vaccination or variolation?
Jenner’s analytical approach to the relationship between exposure to cowpox and the subsequent immunity to smallpox, is reflected in his report3 of 23 case studies involving individuals or groups of individuals 1) who had been exposed naturally to cowpox and then smallpox, 2) who had been naturally exposed to cowpox and were then variolated and 3) those who had experienced neither infection and were then inoculated with cowpox followed by smallpox. The first of the case studies appear to have occurred in 1743 but it was only the last seven of these occurring after 1790 that Jenner became personally aware of or involved with. The most famous of these was the case of Sarah Nelms, a milkmaid on a farm near to Berkeley. Reported as case XVI Jenner observes: “SARAH NELMES, a dairymaid at a Farmer's near this place, was infected with the Cow Pox from her master's cows in May, 1796. She received the infection on a part of the hand …. A large pustulous sore and the usual symptoms accompanying the disease were produced in consequence…”
Image made available Courtesy of Dr Jenner’s House, Museum and Garden.
Jenner was convinced this was a genuine case of cowpox with a clean presentation. Here was the opportunity to test the hypothesis in a rigorous experiment. Jenner identified a young village boy, James Phipps, who had not yet been variolated, and injected the secretions from the Sarah Nelms sores under Phipp’s skin as “two superficial incisions, barely penetrating the cutis, each about half an inch long…” This was in May 1796 and was the first example of a human-to-human vaccination. Two months later Phipps was variolated by the same procedure and “… as I ventured to predict, produced no effect. I shall now pursue my experiments with redoubled ardour”. Jenner’s attempt to get his results published by the Royal Society of London failed for ‘lack of sufficient experimental evidence’. His conviction that this was an enormously important medical advance led him to finance the publication himself. This was not enough however to convince the entire medical community. Skepticism abounded until several renowned London physicians supported Jenner’s procedure.
But is that the whole story?
In 1805 a Dorset farmer, Benjamin Jesty arrived in London on an invitation from the Original Vaccine Pock Institute to describe his cowpox vaccination procedure on his own family which included a real time inoculation of his son Robert with smallpox. This new institute was formed by the anti-Jenner physician George Pearson in an attempt to shift the credit for vaccination discovery away from Jenner. Despite the prevailing view amongst Jenner supporters, it was clear from the records at the time that Jesty had carried out his vaccine attempts some 22 years before Jenner’s experiments with Sarah Nelms and James Phipps, yet until 1805 had been essentially unrecognized. On the basis of this some writers have sought to ascribe the invention of vaccination to Jesty. What is evident however is that while vaccinating his family with cowpox secretions, Jesty appears not to have immediately followed that up with variolation, a sine qua non for proof of any hypothesis on the cowpox protective effect.2 A further intriguing fact is that a third surgeon and older colleague of Jenner, John Fewster who lived in a village near to Berkeley, also appeared to have made the connection between cowpox exposure and smallpox immunity. It has been suggested he presented a paper to the London Medical Society in 1765 entitled “Cowpox and its ability to prevent smallpox” but no evidence of that exists.2,4 Fewster had a lucrative business in variolation the financial success of which may have led him to downgrade the importance of the cowpox approach.2,10 On the other hand, as a colleague and young apprentice member of the same local medical society where Fewster discussed his observations that individuals exposed to cowpox were ‘uninfectable’ with smallpox, it would be surprising if Jenner had not taken on board the connection. So, in chronological order, Fewster, Jesty, Jenner! Equal members of a vaccination trio or professional soloist and amateur accompanists?
As Sir Francis Darwin observed “In science credit always goes to the man who convinces the world, not the man to whom the idea first occurs”5. Is this principle supportable even if common today? In discussing the problem of attribution of credit (also quoting Francis Darwin), Sir William Osler, commenting on the discovery of anaesthesia attributed to William Morton in 1848 observed that, despite many who had practiced or had ideas on anaesthesia, from Diascordes to Hickman in 1844, “…time out of mind patients had been rendered insensible by potion or vapours, or by other methods , without any one man forcing any one method into general acceptance, or influencing in any way surgical practice.”6
Therein perhaps lies the answer to the question that still lingers in the historical literature, with its scientific Whigs and Tories debating the creditworthiness of farmer Jesty’s amateur experiments over Jenner’s scientific method.7 The crucial question it seems to me is not who was first but, had Jesty been the only proponent of cowpox vaccination, would the method have had ‘general acceptance’ and further would it have ‘influenced medical practice’? Even with Jenner’s reputation the vehement objections to the cowpox procedure that included claims that patients receiving the vaccine “rendered them liable to particular diseases, frightful in their appearance and hitherto unknown”8 created serious questions about the efficacy and indeed the morality of the procedure. In assessing the validity of these objections, a Report of the Medical Committee of the Jennerian Society on the subject of vaccination, contributed to by “21 Physicians and 29 surgeons of the first eminence in the Metropolis”, was published in the Belfast monthly Magazine in 18098. In addressing the alleged claims, 22 separate statements based on analysis of the information by the committee were made. The conclusion of the report states “…that it is their full belief, that the sanguine expectations of advantage and security, which have been formed from the inoculation of the cow pox, will be ultimately and completely fulfilled.”
In the end, credit usually gets to the right place
There would seem to be only one historically supportable conclusion. While Jesty was certainly an intelligent amateur who was first to apply the secretions of cowpox as a protection against smallpox, and Fewster was perhaps closer to being in a position to turn the phenomenon into a generally accepted procedure but chose to maintain his variolation business for whatever reasons, it was the painstaking scientific methods and the driven ardour of Edward Jenner that overturned the engrained establishment skepticism and established vaccination as a widely adopted procedure. By 1800, Jenner had provided vaccine to a colleague in Bath, England who passed it to a Professor in Harvard, USA who then introduced vaccination into New England and with Thomas Jefferson’s mediation, into Virginia.9 As a result the US National Vaccine Institute was set up by Jefferson. By 1803 it was reported that 17,000 vaccinations had been performed in Germany alone, 8000 individuals of which had been tested by variolation and found to be immune to smallpox. In France, Jenner was revered by Napoleon for his vaccination impact on the health of the Grande Armée, despite being at war with England. By 1810 or so cowpox vaccination had been adopted in most of Europe, USA, South America, China, India, the Far East and many other parts of the globe with outstanding success. All this as a result of Jenner’s almost fanatical belief in the importance of a correct procedure in preparing and administering the cowpox vaccine and critically, his ability to garner support from the highest scientific and medical influences.
Had there been a Nobel Prize committee in 1805 would Jenner and Jesty have shared the prize? We shall never know but it’s mighty intriguing to think about!
© Anthony R Rees, January 5th, 2015
References
1. Weiss, R.A. & Esparza, J. The prevention and eradication of smallpox: a commentary on Sloane (1755) ‘An account of inoculation’. Phil. Trans. R. Soc. B 370: 20140378. Note: In fact Jesty did variolate his family but not until 15 years later in 1789.
2. Boylston, A.W. Defying Providence: Smallpox and the Forgotten 18th Century Medical Revolution. Create Space Independent Publishing Platform. See pp99-112 & 151-166.
3. Jenner, Edward. An inquiry into the causes and effects of the variolae vaccinae, a disease discovered in some of the western counties of England, particularly Gloucestershire, and known by the name of the cow pox. London, England: Sampson Low, 1798.
4. Jesty, R. & Williams, G. Who invented vaccination? Malta Medical J. 2011, 23, 29-32
5. Darwin, Sir Francis. First Galton Lecture. Eugenics Review, 1914, 6, 1. Note: many authors wrongly attribute this quote to Galton or Osler.
6. Osler, Sir William. The First Printed Documents relating to Modern Surgical Anesthesia. Reprinted from the Proceedings of the Royal Society of Medicine, 1917-18, Vol. XI, pp. 65-69.
7. Pead, P.J. The origins of vaccination: history is what you remember. J. Roy. Soc. Med. 2014, 107, 7
8. The Jennerian Society on Vaccination. The Belfast Magazine, 1809, 3, 421-423
9. Riedel, Stefan. Edward Jenner and the history of smallpox and vaccination. BUMC Proceedings 2005;18:21–25