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The New England Journal of Medicine -- February 1, 2001
-- Vol. 344, No. 5
The Last Smallpox
Epidemic in Boston and the Vaccination Controversy, 1901-1903
One hundred years ago, Boston had its last epidemic
of smallpox. We
describe this final epidemic,
the controversy over
compulsory vaccination,
and ethical issues that remain relevant today.
Epidemiology
and Protection through Vaccination
In May 1901, an outbreak of smallpox, initially unrecognized,
was followed by a series of outbreaks in various neighborhoods of Boston. (1)
From 1901 to 1903, there were 1596 cases of smallpox (Figure
1), with 270 deaths, (1,2,3)
in a city with a population of approximately 560,900. The attack rate was 3
cases per 1000 persons, with a case fatality rate of 17 percent.
Of 243 consecutive patients with smallpox who were admitted to
the smallpox
hospital on Southampton Street, 18 (7 percent) were black, (4)
although blacks made up only 2 percent of Boston's population in 1900. (5)
Of the 238 patients whose birthplace was identified, 49 percent were
immigrants, whereas only 35 percent of the city's residents were foreign-born (5);
Canadian-born residents, accounting for 21 percent of the patients, made up 9
percent of Boston's population at the time. During the epidemic, 60 percent of cases
occurred in males. (1,2,3)
Among 754 patients with smallpox who had evidence of vaccination (Figure
2), there were 82 deaths (case fatality rate, 11 percent), whereas among
842 unvaccinated patients, there were 188 deaths (case fatality rate, 22
percent). The law requiring that children be vaccinated in order to attend
public school, which had been enacted by the state in 1855, appeared to be
effective in providing protection against the epidemic. A review of 700 cases showed that 130
(19 percent) occurred in children 1 to 5 years old, but only 21 (3 percent)
occurred in children 6 to 10 years old (6);
the number of children in each age group was similar. (5)
Efforts to
Control the Epidemic
In the fall of 1901, the Boston Board of Health took
steps to control the epidemic.
Dr. Samuel Holmes Durgin, a member of the Harvard Medical School faculty, was
chairman of the board. (7,8)
All patients with smallpox,
except those who were extremely ill, were taken to special facilities. (1)
A detention hospital on Southampton Street served as the main hospital. When
additional beds were needed, the quarantine facilities on Gallop's Island, in Boston Harbor, were hastily
expanded. The Boston
Health Department conducted a program of "thorough disinfection, vaccination and revaccination
of all persons who have been in contact or exposed to the patient, and
surveillance of the suspects for two weeks." (9)
A general program of voluntary vaccination was initiated.
Free vaccination
stations were established, and physicians visited businesses to vaccinate
employees. Vaccination
was performed with the use of glycerinated liquid vaccine or vaccine dried on
an ivory or bone "point." (10)
Vaccine obtained from humans ("humanized" vaccine), transmitted from
person to person, was believed to be a source of transmission of other
infectious diseases, and by 1900, the virus was usually propagated on the skin
of heifers on commercial "vaccine farms." (11)
However, there was no regulation of the production and quality of smallpox vaccine. An
editorial in the Boston
Medical and Surgical Journal conceded that some vaccine manufacturers practiced
"unscrupulous methods" of production and advertising. (12)
Legislation enacted shortly after the epidemic had ended provided for state-sponsored production
of vaccine. (13)
Federal legislation enacted in July 1902 regulated the manufacture of vaccine
for interstate sale. (14)
Although generally safe, vaccination
had risks. Generalized vaccinia, ulceration, abscess formation, cellulitis,
secondary sepsis, and tetanus were potential complications.
By December 1901, more than 400,000 Bostonians had
been vaccinated. Nonetheless, continued reports of smallpox cases led the Board of Health to order
that "all the inhabitants of this city who have not been successfully
vaccinated since January 1, 1897, be vaccinated or revaccinated
forthwith." (15)
A program of house-to-house vaccination
was initiated in January (Figure
3), with physicians sent to the most affected areas of the city: East Boston, South Boston, Charlestown, the
North End, the West End, and parts of Roxbury and Dorchester. (1)
The instructions given to the physicians were as follows: "Vaccinate all
who are willing and are not too ill. No force to be used. Make skin clean
before vaccinating. Make two scarifications. Make no scarification more than
one-fourth inch in diameter. Do not make the blood flow. Rub the lymph well
into the wound and secure its drying. Caution [the patient] carefully against
breaking the vesicle or doing other injury." (17)
Persons who refused vaccination
were subject to a $5 fine or a 15-day jail sentence. (16)
The homeless were blamed for spreading smallpox. A 1904 editorial in
the Lancet stated, "What a potent factor in maintaining the prevalence of smallpox is that unemployed
and largely unemployable degenerate [person].... The fact that this parasite
upon the charity and good nature of the community is in his turn a vehicle for
the spread of other parasites, both animal and vegetable, is common knowledge
but practically no compulsory steps have been taken to curtail seriously the
vagrant's movements." (18)
In November 1901, the Boston
Board of Health ordered "virus squads" to vaccinate men living in
inexpensive rooming houses.
A reporter for the Boston Globe accompanied a squad one night and
described the scene: "Every imaginable threat from civil suits to
cold-blooded murder when they got an opportunity to commit it, was made by the
writhing, cursing, struggling tramps who were operated upon, and a lot of them
had to be held down in their cots, one big policeman sitting on their legs, and
another on their heads, while the third held the arms, bared for the
doctors." (19)
One "fighting tramp," who "went down in a heap on the
floor" from the blow of a policeman's club, received both vaccination and suturing of
his scalp. In hearings on compulsory vaccination, opponents alleged that in Massachusetts,
boards of health "in many cases had acted with autocratic power and
forcibly assaulted persons to vaccinate them." (20)
Opponents of
Compulsory Vaccination
The Board of Health was concerned about criticism
by the Anti-Compulsory Vaccination
League and considered Boston
"practically a hot-bed of the anti-vaccine heresy." (21)
Opponents of vaccination
questioned its safety and efficacy. They believed that compulsory vaccination was a violation
of civil liberties and that "from the standpoint of free citizenship no
government should forcibly inflict on any individual enjoying all other rights
of the nation, a disease [vaccine] loathsome in its origin, and not free from
danger to life, and with, at all events, impairment of bodily health, at least
of a temporary nature." (22)
In January 1902, legislation was proposed to
repeal the state's compulsory-vaccination
laws. The leading opponents of vaccination,
including a number of physicians, testified in favor of the legislation. (23)
Arguing against the proposed repeal were prominent physicians, business
leaders, and educators, including William Councilman, a pathologist at Harvard
Medical School, and Frank Draper, the president of the Massachusetts Medical
Society at the time. Those who supported vaccination prevailed, and in February,
"all the antivaccination bills were reported adversely." (24)
This epidemic
led to a landmark legal case on the constitutionality of compulsory vaccination. (25,26)
In Jacobson v. Massachusetts, a citizen challenged a Massachusetts law that
allowed the Cambridge Board of Health to fine him for refusing revaccination.
Jacobson argued that the law opposed "the inherent right of every freeman
to care for his own body and health in such a way as to him seems best." (25)
In 1905, the U.S. Supreme Court voted seven to two in favor of the state,
ruling that although the state could not pass laws requiring vaccination in order to
protect an individual, it could do so to protect the public in the case of a
dangerous communicable disease.
The Pfeiffer
Affair
In November 1901, Durgin (the chairman of the Boston Board of Health) posed
an extraordinary challenge: "If there are among the adult and leading
members of the antivaccinationists any who would like an opportunity to show
the people their sincerity in what they profess, I will make arrangements by
which that belief may be tested and the effect of such exhibition of faith, by
exposure to smallpox
without vaccination,
be made clear." (27)
In January 1902, Dr. Immanuel Pfeiffer, a Danish
immigrant, requested that he be allowed to visit a smallpox hospital, ostensibly to study the
disease, without undergoing vaccination.
Pfeiffer, a physician who advocated fasting and hypnotism, was at one time
president of the American Psychic Society. (28)
A vehement critic of the Board of Health, he apparently thought that people in
good health were not at risk for contracting smallpox -- a belief that was not representative
of the views expressed by those who opposed vaccination. The Pfeiffer bill, which would have
required "obtaining the consent to inject any poisonous substance into the
body of any person," (29)
was one of the antivaccination bills voted down in February 1902.
The 60-year-old Pfeiffer had not been vaccinated
since infancy. In an unprecedented move, Durgin lifted the strict requirement
of recent, successful vaccination
for all health workers entering the Gallop's Island smallpox hospital. Pfeiffer visited the hospital
on January 23, 1902, and was escorted among more than 100 patients with smallpox by the physician in
charge, Dr. Paul Carson, who reportedly suggested that he smell the odor of a
patient's breath. (28)
Health officers surreptitiously observed Pfeiffer after the visit, and on
February 8, 1902, he was found to be critically ill in his home in Bedford. The
following day, the headlines read, "Pfeiffer Has Smallpox. Anti-vaccinationist
May Not Live." (30)
Physicians on the Board of Health initially predicted that Pfeiffer would die,
but he survived. Durgin publicized the fact that no cases of smallpox had occurred among
the recently vaccinated physicians who had visited the hospital. The press
acknowledged his triumph: "Chairman Durgin comes up smiling." (31)
An editorial stated, "It is a salutary lesson to the anti-vaccinationists,
and it is destined to live in the annals of preventive medicine." (32)
It is far from clear that the incident served as a
"salutary lesson." Pfeiffer's theories on smallpox were his own, and opponents of
compulsory vaccination
were among those who condemned his "foolhardiness." (33)
One newspaper article questioned the ethics of Durgin's actions: "Was Dr.
Durgin right in allowing Dr. Pfeiffer to visit the hospital without being
vaccinated?... 'It was the right thing to do, as it was good for the greatest
number,' was the cool, analytical response of the chairman of the board of
health." (34)
The Board of Health had not placed Pfeiffer under any restrictions after his
exposure at Gallop's Island. The town of Bedford considered suing the city of Boston, charging that smallpox had been
"imported because of the inexcusable negligence of the health authorities
of Boston." (35)
Epilogue
After the epidemic ended, in March 1903, there were sporadic cases of
smallpox in Boston. A total of 108 cases,
4 of which were fatal, were reported between October of that year and 1932,
when the last case
occurred. (36)
The controversy over
vaccination
persisted. After a failed attempt in 1926 to extend compulsory smallpox vaccination to children attending private
schools, a Boston
Health Department report complained bitterly about "active antivaccination
propaganda." (37)
Smallpox made its
final appearance in the United States in 1949, in Hidalgo County, Texas. In
1971, with no cases having been reported in the United States in the previous
22 years but with six to eight deaths per year due to complications of vaccination, the U.S. Public
Health Service formally recommended the discontinuation of routine vaccination. (38)
This epidemic
illustrates the importance of applying modern medical science (in this case, vaccination) to an acute
public health problem, educating the medical community and the general public
about the benefits of prevention, and having public debate on the pros and cons
of public health policies aimed at prevention. Some aspects of the epidemic remain disturbing.
The Board of Health's policy toward the homeless and the challenge to those who
opposed vaccination
to expose themselves to smallpox
showed a disregard for civil liberties and for ethical concerns. Such abuses
underscore the importance of an ethical framework for public health and
medicine that includes the oath to "do no harm," respect for
individual autonomy, and the requirement of informed consent.
With advances in the safety and efficacy of
vaccines and a greater understanding of the immune system, public approval of vaccination increased in the
20th century. Ultimately, a concerted worldwide campaign based on immunization,
surveillance, and containment of disease would achieve the goal of eradicating smallpox, which Edward Jenner
had contemplated two centuries earlier. (39,40)
Michael R. Albert, M.D.
National Cancer Institute
Bethesda, MD 20892-1908
Kristen G. Ostheimer, M.A.
Massachusetts General Hospital
Boston, MA 02114
Joel G. Breman, M.D., D.T.P.H.
Fogarty International Center
Bethesda, MD 20892-2220
We are indebted to Gerald Keusch of the Fogarty
International Center, National Institutes of Health, and to Stephen Katz of the
National Institute of Arthritis and Musculoskeletal and Skin Diseases, National
Institutes of Health, for their critical reading of the manuscript.
Source
Information
Address reprint requests to Dr. Breman at the
Division of International Training and Research, Fogarty International Center,
National Institutes of Health, Bldg. 31, Rm. B2C39, 31 Center Dr., MSC 2220,
Bethesda, MD 20892-2220, or at jbreman@nih.gov.
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Copyright © 2001 by the Massachusetts Medical Society.
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