Medicine in Canada Smallpox and its control in Canada John W.R. McIntyre, MB BS; C. Stuart Houston, MD vening peninsula between Trinity and St. John’s.2 By the Abstract first week of October 1800 Clinch had vaccinated additional people in the adjacent settlements of St. John’s and Portugal EDWARD JENNER’S FIRST TREATISE IN 1798 described how he Cove, and by the end of 1801 he had vaccinated 700 peo- used cowpox material to provide immunity to the re- ple.2 William R. LeFanu’s definitive bibliography of Jenner3 lated smallpox virus. He sent this treatise and some credits Clinch with being the first vaccinator in North cowpox material to his classmate John Clinch in Trin- America, before Benjamin Waterhouse, who vaccinated his ity, Nfld., who gave the first smallpox vaccinations in own sons in July 1800 and then popularized vaccination in North America. Dissemination of the new technique, Boston.4 Sadly, exact dates for Clinch’s first vaccinations are despite violent criticism, was rapid throughout Europe unavailable for conclusive proof of his priority. Clinch is 1 and the United States. Within a few years of its discov- honoured by a memorial plaque in Trinity. ery, vaccination was instrumental in controlling small- pox epidemics among aboriginal people at remote trad- Transportation of cowpox vaccine ing posts of the Hudson’s Bay Company. Arm-to-arm transfer at 8-day intervals was common through most of How was Jenner’s vaccine sent to Newfoundland? the 19th century. Vaccination and quarantine elimi- Transportation of the vaccine, whether in the form of lymph or dried material, was an uncertain enterprise. It nated endemic smallpox throughout Canada by 1946. might be stored and transported on narrow pointed slivers The last case, in Toronto in 1962, came from Brazil. of ivory about 3 cm long, called “points,” or on squares of glass with a thin coat of gum arabic mucilage.5 Clinch re- ceived his cowpox matter from Jenner within quills and on n Dec. 1, 1796, Dr. John Clinch, a medical mis- impregnated threads.1,2 Colonel George Landmann, living sionary at Trinity, then the second largest settle- in Quebec City in November 1801, received his “precious Oment in Newfoundland, sent a letter to Dr. Edward yellowish lymph” between small squares of plate glass.6 Jenner in Gloucestershire. Clinch asked for further infor- Dr. John Warren of Boston received it from England “in a mation about using cowpox pustule matter as a vaccination closely sealed phial.”7 against smallpox.1 Jenner had vaccinated his first subject Communal vaccination was made practicable by trans- only 6 months earlier. By June 1800, when Jenner pub- ferring lymph 8 days after vaccination from the original lished his famous pamphlet, An Inquiry into the Causes and person vaccinated with cowpox to a succession of people. Effects of the Variolae Vaccinae, describing his vaccination ex- The longest duration of vaccine transport using children periments on 23 subjects, Clinch probably had been vacci- was the 3-year Balmis expedition from Spain that began in nating people in Newfoundland for a year or more. 1803.8 The Maria Pita carried 22 orphan boys 3 to 9 years Jenner and Clinch, both born in 1749, had been class- of age, Balmis, a deputy surgeon, 2 assistants, 2 first-aid mates at Reverend Dr. Washbourn’s school in Cirencester, practitioners, 3 male nurses and the rectoress of a Santiago Gloucestershire, before they went to London together to orphanage. The boys were vaccinated in sequential pairs be pupils of the distinguished surgeon John Hunter.2 Jen- every 9 or 10 days. At ports along the route to South ner returned to his home area, but Clinch practised 3 years America and the Philippines, homes were found for the in Dorset near Poole, the main shipping port for New- orphans and more children were brought on board. foundland. In 1775 Clinch moved to Newfoundland to Thereby vaccination “girdled the world.”8 In British India practise in Bonavista. After 8 years he moved to Trinity, only boys of low caste were considered suitable for the where he also preached the Anglican sermons on Sundays. purpose.9 Jenner’s nephew, George Jenner, aiming for a similar church–medicine career, very likely began his medical ap- Variolation using live smallpox virus prenticeship under Clinch at Trinity in 1789.2 On July 15, 1800, a second shipment of vaccine from Ed- Before Jenner pioneered use of the safer cowpox vac- ward Jenner reached Clinch; one of these two vaccine ship- cine, the technique of variolation, or “smallpox inocula- ments, most likely the first, came via George Jenner, by tion,” was an established practice in parts of Asia and then the Anglican minister at Harbour Grace, on the inter- Africa. In China, insufflation of dried smallpox crusts into CMAJ • DEC. 14, 1999; 161 (12) 1543 © 1999 Canadian Medical Association or its licensors Smallpox in Canada the nostrils caused a less severe form of smallpox than that later lay for 6 weeks in the same bed with a 10-year-old boy occurring naturally.5 A second method, of rubbing liquid with smallpox, to demonstrate her immunity.10 from a smallpox pustule into a small scratch on the arm, The disease produced by “scratch” variolation was appre- found favour in the rest of the world and reached Constan- ciably milder than naturally occurring smallpox: the fever tinople in 1679.10 Either method of variolation provided was milder, the disease was of shorter duration, and there life-long immunity. These practices were reported verbally were fewer pustules.15 However, fatal smallpox often result- to a meeting of the Royal Society in 170011 but were not ed among contacts, and it was some years before either in- published in Philosophical Transactions in London until 1713 oculation of the entire community or isolation of those re- and 1717.12,13 ceiving variolation became standard practice.5 Variolation After Lady Mary Wortley Montagu, wife of the British had a death rate of 2% in the first 8 years of practice Ambassador to Turkey, variolated her 6-year-old son at through 1729,10 a notable improvement over the 20% to Adrianople on Mar. 18, 1718, Europeans sat up and took 30% from naturally occurring smallpox, which in that era notice. On her return to England, Lady Mary gained the was encountered at some time in almost everyone’s life.5 support of the Princess of Wales.14 In 1721, 6 condemned The first known use of variolation in what is now convicts, 3 men and 3 women, were inoculated with live Canada was in Quebec in 1765.16 In 1769, James Latham, a smallpox virus in the presence of the royal physicians Sir British military surgeon, instructed by Robert and Daniel Hans Sloane and Dr. John George Steigertahl. In return, Sutton in England, variolated 303 people, including promi- all 6 lives were spared from hanging. One of the women nent members of English and French families in Quebec N HUDSON BAY Ft. Churchill Ft. Chipewyan . R asca b York a R. h n . Factory t o ls R A e s N e a y Île-à-la-Crosse La Ronge H Oxford Cumberland House Buckingham Moose House Lake Edmonton House Hudson's House House The Pas Carlton House . R n Ft. Pelly a ew Saskatc h Ft. Ellice Ft. Brandon Garry Ft. House R e Union d M M isso iss R uri R ou iv . r e i r R . Christine Kenney Fig. 1: Western interior of Canada in 1832. Based on a map from the Hudson’s Bay Company Northern Department reproduced by Ray,22 with permission. 1544 JAMC • 14 DÉC. 1999; 161 (12) Smallpox in Canada City and, later, 200 people in Montreal, without fatality. By Smallpox on the western plains the time of his departure in 1770, Latham had variolated 1250 people in Canada.17 In the west, the worst and most widespread smallpox To a large extent, British troops in Canada had been epidemic came north from the Missouri River in the sum- variolated. In contrast, several of the 13 colonies, before the mer of 1781 (Fig. 1). It reached susceptible aboriginal peo- American revolution, had passed laws against variolation. ple, “virgin soil” for the smallpox virus, along the Although George Washing- Saskatchewan River by the ton’s troops were variolated end of the year.18 Mitchell during the siege of Boston, Oman met some surviving and later the practice was Indians in the Eagle Hills made compulsory for all new region of present-day Sas- army recruits, such was not katchewan in the fall of the case for American troops 1781; the survivors were involved in the assault on “weak and just recovering” Quebec. The severity of the from smallpox; Oman smallpox outbreak among “looked into the tents, in them caused them to retreat many of which they were in July 1775. “Indeed, small- all dead.” When he pox saved Canada for the reached Fort Buckingham British Empire.”10 (near present-day Elk In 1796, the authorities Point, Alta.), which he had allowed the variolation of founded a year earlier, “all Mohawk Indians in Upper Fig. 2: York Factory in the 1770s, where early quarantine efforts was solitary silence ... there Canada, and of Indians near in the summer of 1782 helped to prevent a smallpox epidemic. was no Indian to hunt for 17 Kingston. Variolation con- [Coloured engraving from a drawing by Samuel Hearne.] us. ... three-fifths had tinued for over half a century died.”19 after the introduction of William Tomison ar- smallpox vaccine, effectively ceasing in Canada only by an rived at York Factory on Hudson Bay on July 2, 1782, con- Act of Parliament in 1853.16 firming news of the epidemic in the interior (Fig.