Understanding Vaccination Through the Lens of Inoculation: A Review of Defying Providence

When the history of vaccination is discussed it, naturally, begins with the path-breaking step taken by Edward Jenner in the late 1700s. Jenner’s use of cowpox to protect against smallpox—an action that would culminate in the eradication of smallpox from the planet under the aegis of DA Henderson—is often discussed without any knowledge of the context that conditioned the development of the first vaccine in history.

Dr. Arthur Boylston’s Defying Providence: Smallpox and the Forgotten 18th Century Medical Revolution provides that valuable context. Boylston’s book, which is the result of extensive research, adds much detail to the means of controlling smallpox that existed before vaccination – i.e. inoculation. Inoculation is often treated as a historical relic in the path towards vaccination and given short shrift by many and often damned as a means by which smallpox spread but it is much more than that, as Boylston shows.

Inoculation was an ancient practice that rose in prominence in England and Boston (under the direction of another Dr. Boylston) in the 1700s. It involved the intentional infection of someone with smallpox via a small cut in the skin. Such artificial cases allowed an often minor infection to ensue conferring immunity against natural infection. Make no mistake, the artificial infection was true smallpox and, in rare instances, could kill and also had the ability to spread. However, it is crucial to not drop the context in which it was used – a time in which smallpox was a major killer in which risk-benefit ratios strongly favored the use of inoculation.

Boylston’s book provides a much-needed history of how this practice gained in acceptance, how the evaluation of its efficacy led to the foundations of evidence-based medicine, and how a specific phenomenon led to Jenner’s innovation. 

The phenomenon of those who had cowpox being protected from smallpox is cloaked in the myth of the fair complexion of the milkmaid but the actual truth is much more interesting scientifically.

Cowpox was an affliction known to farmers and the inability of an inoculation to take (i.e. produce a case of mild smallpox) in those with cowpox began to be known before Jenner. Jenner and others reasoned that because of the resistance to inoculation, cowpox might be protective against smallpox infection. In effect, Jenner sought to substitute vaccination (with cowpox) for inoculation, seeing if artificial cowpox would work the way natural cowpox did with respect to smallpox protection. Vaccination was a relatively safer alternative to inoculation and could not spread smallpox. The resistance to Jenner’s vaccination that occurred upon introduction can be seen not just as a reaction against the use of material from a cow but also hesitancy to discard inoculation, which had been a major component of smallpox control until then.  Indeed inoculation, as the title of the book makes explicit, allowed humans to defy Providence and take charge of the trajectory of their lives by protecting themselves from smallpox.

Dr. Boylston deserves much credit for writing this important history and illuminating the origins of vaccination—another means to defy Providence—by giving much due credit to inoculation and the inoculators.