Once upon a time there was smallpox. One of the most loathsome diseases ever to afflict human kind, smallpox not only killed but maimed. Death rates were typically between 25 and 30 per cent, and survivors might not only be blinded and their skins scarred and pitted from the pocks, but they also suffered internal tissue damage that affected lung function and other life processes. It was an ancient disease, and like many other such had relations that afflicted animals, such as cowpox, horse pox and monkey pox, although smallpox itself was specific to humans. Over many centuries, folk practices evolved in an effort to mitigate the damage caused by the disease. The Chinese developed the practice of variolation or inoculation, deliberately inserting smallpox matter obtained from a mild case of the disease under the skin in the hope of achieving immunity through a relatively benign attack; elsewhere people tried for the same effect by holding the crusts from smallpox scabs in their hands for hours, or by inhaling the dust from ground up crusts. In rural England, it was noted in farming communities that those who had been infected with cowpox seemed to be immune to the scarier human version. In 1796, a Gloucestershire medical practitioner, Edward Jenner, famously conducted the first ‘scientific’ trial of the efficacy of cowpox inoculation in preventing smallpox, and demonstrated that it did indeed do so. Designated ‘vaccination’ in honour of the cowpox matter (vaccinia), Jenner’s discovery was widely utilised in Europe and elsewhere in the two centuries that followed, contributing eventually to the official eradication of smallpox in 1979.
Much has been written on the history of smallpox and vaccination in recent years, from the local and popular such as J. R. Smith’s The Speckled Monster,(1) to Peter Baldwin’s magisterial survey of the introduction of vaccination legislation in nineteenth-century Europe,(2) and Stanley Williamson’s lively but unscholarly The Vaccination Controversy.(3) The topics have a number of claims to historical attention. Quite apart from the impact of smallpox on human health and societies, there are practical and ethical issues surrounding vaccination, issues of risk assessment, the promotion and practice of variolation and vaccination by different groups, the emergence of vigorous anti-vaccination movements in the nineteenth century, the nature and quality of vaccines, and the methods used to stamp out the disease at various times and in different contexts. In some countries, such as India, but also in early nineteenth-century England, vaccination also raised religious issues. Among these various historical strands, historians of smallpox in Britain have largely focused on the mid to late nineteenth century, on the introduction of vaccination legislation and the emergence of opposition. Anti-vaccinationism in particular has been the subject of essays by such distinguished historians as Roy McLeod, Roy and Dorothy Porter and Logie Barrow, and a recent monograph by Nadja Durbach.(4) For the eighteenth century, Peter Razzell has fought the priority dispute corner (Jenner was not the first to take up the cowpox option) and defended the effectiveness of variolation in reducing the burden of smallpox before Jenner. Other parts of the British story have meanwhile remained uncharted, and the publication of Deborah Brunton’s monograph is welcome for opening up the professional and political sides of the vaccination issue, and especially for extending the geographical focus of inquiry to include Ireland and Scotland.
Brunton’s approach is, none the less, a somewhat restricted one. The principal focus of the book is on ‘the shaping of public vaccination … through its formative years from 1840 – the passing of the first Vaccination Act – to 1874’ – the year which saw the passing of the last enactment to enforce compulsion as well as the end of a severe smallpox epidemic that stretched the capacity of the public services to control the disease to its limit (p. 2). It contributes, therefore, another chronological section to the fragmented literature on the broader topic. Second, Brunton’s account is derived from the perspective of the medical practitioners, which, while novel in historical terms and providing some intriguing insights, also leaves the reader feeling that only one side of a multi-faceted story has been told. The directed focus also helps to flatten the prose. Part of the problem with Brunton’s account is that while her writing is clear and comprehensible, it is decidedly lacking in colour, quotation and the evocation of personalities that bring history to life. Where, for example, is William Farr, compiler of abstracts at the General Register Office, who is quoted by Williamson (p. 151) as inveighing against the 1853 Vaccination Act:
Anyone who had the slightest administrative capacity could have foretold its failure … What hindrance these certificates throw in the way of a man whose (vaccination) station is full of children, or who wants to get away to other patients or to a woman at a distance in labour, we can easily conceive.
Brunton points out (p. 49) that such bureaucracy as the completion of two vaccination certificates per operation performed was a novelty in 1853, but the immediacy of any apt illustration is omitted.
The book falls into three parts. Six chapters deal with England and Wales, two with Ireland, and one with Scotland. (To list Wales separately in the title is slightly disingenuous: Wales had no administrative identity separate from England in nineteenth century.) This unevenness of detail has something to do with the availability of relevant historical records, but also reflects the fact that the legislative provisions for vaccination were achieved later, and more quickly and easily, in Scotland and Ireland. The English chapters detail the tortured history of attempts to construct a viable vaccination programme. Parliament’s initial legislative reluctance to interfere in the free market economy and with the liberty of the individual gave way by 1840 to a recognition that some systematic provision was needed, and a reluctance to provide opportunities for patronage. This resulted in the establishment of an unsatisfactory system whereby free vaccination was offered through the poor law – unsatisfactory because popular dislike of the poor law tainted effective delivery. At the same time practitioners’ desire for social standing, financial security and liberty of practice led them to resent and occasionally resist efforts to organise public vaccination. The issue of payment for their services was especially sensitive.
Brunton wants us to believe that the early nineteenth-century doctors were a ‘unified, politicised profession’ (p. 53), but her case rings somewhat hollow in the absence of a rigorous quantitative analysis of medical correspondence and writings on the subject of vaccination and against Irvine Loudon’s depiction of a deeply fractured and fractious profession in the years up to the Medical Act 1858.(5) As late as 1883, indeed, Lyon Playfair could refer in House of Commons debates over the 1883 Medical Act Amendment Act to ‘this long-agitated profession’.(6) Brunton downplays the overcrowded and competitive nature of the nineteenth-century medical profession – the livelihoods of these men depended on their ability to gain and retain enough fee-paying patients. She points to the formation of medical societies and medical journals in the early decades of the century as evidence of unity and politicisation, without admitting that attrition rates among both societies and journals were very high – few survived more than a year or two or an issue or three, the Lancet (founded 1837) being an exception. Some claims read oddly – Brunton states that there were a few large national medical societies at this period, citing the Provincial Surgical and Medical Association (PMSA) founded in 1832 and the British Medical Association (BMA) ‘founded in 1836’ (p. 23). In fact the PMSA was the predecessor of the BMA, and the latter was not instituted as such until 1856; the PMSA and the BMA were effectively the same society.
The insecurity of Brunton’s argument seems to be demonstrated in the context of the 1853 Vaccination Act, which introduced compulsory infant vaccination. Whereas the 1840 Act had encountered medical opposition orchestrated by the radical reforming editor of The Lancet, Thomas Wakley, the 1853 Act encountered little opposition. The House of Commons received just seven petitions against the Bill from medical men, and, as Brunton notes, even so the impact of these was ‘dissipated’ since the petitioners made different demands (p. 47). Surely a ‘unified and politicised profession’ would have co-ordinated its responses, and found vociferous champions of their cause, even in the face of Wakley’s retirement from The Lancet and the reluctance of other journal editors to organise a campaign against the Bill? Brunton sees the newly founded Epidemiological Society, which espoused compulsion as a necessary measure, as a divisive influence. The question remains whether the issue of compulsion would in any case have arisen further to the failings of the 1840 Act, and at a time when several other European states had already set an example in this direction.
If the situation was unsatisfactory and tangled in England, matters were not much better, initially at least, in Ireland. Government policy towards Ireland was to bring its legislation and administration into line with that of England and Wales, but it failed to take into account significant differences between the administrative structures of the two countries. Thus the 1837 new poor law in Ireland permitted medical relief only within the workhouse, where in England and Wales it was still allowed in the homes of the poor – a concession which facilitated the task of vaccinators. The Irish poor law authorities were still struggling to deliver the new provisions, and had difficulty taking on board the 1840 provision for public vaccination, while Irish medical practitioners took the same hostile view to public provision as the English. The situation was resolved through further poor law reform under the 1851 Medical Charities Act, and the a vaccination programme aligned to complementary government administrative services such as the registration of births: public vaccination became ‘an integral part of the new medical service’ (p. 125). As in England, where John Simon, Chief Medical Officer at the Medical Department of the Privy Council (not the Medical Office, as Brunton refers to it), determined the course of vaccination provision, Irish policy was developed under the aegis of a medical Poor Law Commissioner, John McDonnell. McDonnell, however, took a much less controlling attitude towards his responsibilities than Simon. The loosely regulated system which he oversaw proved much more effective in delivering results than its English counterpart.
The John Simon/John McDonnell contrast introduces the second major theme of Brunton’s argument – again from the medical profession perspective – of the rise and significance of expertise in this period. Both Simon and McDonnell were medical experts within government. Their positions signalled both the rising power and influence of the profession, and the emergence of further fractures within it. The British medical profession in general was deeply suspicious of expertise, which it equated with quackery, and remained so until at least the inter-war period. English general practitioners already regarded the Royal Colleges of Physicians and Surgeons with considerable mistrust (for political rather than strictly professional reasons), and the development of medical specialities during the nineteenth century contributed an additional dimension of tension and mistrust. Experts could be viewed as unfair competition in an overcrowded market for medicine, and policies designed by and favouring experts as deliberately undermining of the interests of general practitioners. McDonnell, however, was not seen to act against the interests of his fellow practitioners. Although he seems to have been appointed shortly after the 1851 Medical Charities Act, and Simon not until 1856, Brunton notes that he ‘showed no inclination to follow Simon’s lead’ in implementing a closely monitored system of vaccination through specially appointed public vaccinators (p. 125).
In both England and Ireland, specialists working within government determined the course of vaccination policy. In Scotland, by contrast, practitioners outside government took and held the initiative. Brunton argues that Scotland had a unique political landscape, in which links to Westminster were minimal and which facilitated a large degree of self-regulation. The principal medical institutions, she argues, played an important part in initiating new administrative measures. Here Edinburgh’s Royal College of Physicians, which unlike its English counterpart claimed to represent all Scottish practitioners, took the lead in ensuring that free vaccination was limited to paupers. As in Ireland, Scotland ended up with a flexible system and little bureaucratic machinery of enforcement. Despite the lack of enforcement mechanisms, vaccination against smallpox was widely accepted in Scotland – ‘surprisingly’, Brunton notes (p. 9). Similarly, she finds that the results of public vaccination in Ireland ‘present the historian with a conundrum ... that the successful control of smallpox in the 1860s was achieved with a level of vaccination similar to that in England and Wales’, while anti-vaccination sentiment was also absent – as in Scotland (p. 140).
Brunton’s surprise at the absence of anti-vaccinationism and the comparative effectiveness of the loosely regulated systems operating in Ireland and Scotland reflects perhaps on the narrow medical focus she has chosen for her study. While Scotland and Ireland experienced sustained out-migration during the nineteenth century, England experienced in-migration and rapidly expanding international trade; and epidemic strains of smallpox were commonly imported from the continent of Europe. Brunton makes little reference to epidemiological pattern, but population movements, transport and communications, and the nature and timing of epidemic incursions are also factors to be taken into account in evaluating the comparative success of vaccination programmes. The nature of programme delivery was also important. Brunton outlines this, but does not seem to follow through its wider implications. Where England sought to impose a new system of vaccination provision through the unpopular poor law, both Ireland and Scotland chose rather to work through traditional channels of medical provision and charity – the traditional dispensaries in the former, in the latter dispensaries and hospitals in the cities, and church ministers, schoolmasters, midwives and other lay practitioners in the countryside. The adoption of existing health providers as the dispensers of the new operation may have been critical, while the influence of the church(es) in particular might be worthy of further examination. More broadly still, class and gender factors were also important at different times and in different places. Brunton’s medical world is curiously disassociated from other social spheres and from the wider epidemiological context within which her story took place. The insights she provides into contemporary medical issues are very valuable, but would have been enriched by placing the story within a broader historical context.
The author is very grateful for this review, but does not wish to comment further.
- J. R. Smith, The Speckled Monster: Smallpox in England, 1670–1970, with Particular Reference to Essex (Chelmsford, 1987). Back to (1)
- Peter Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge, 1999). Back to (2)
- Stanley Williamson, The Vaccination Controversy: the Rise and Fall of Compulsory Vaccination for Smallpox (Liverpool, 2007). Back to (3)
- Nadja Durbach, Bodily Matters: the Anti-Vaccination Movement in England, 1853–1907 (Durham, NC, 2005). Back to (4)
- Irvine Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford, 1986). Back to (5)
- Hansard, British Parliamentary Debates, cclxxxix, 24 June 1884, col. 1263. Back to (6)