About the collection About the collection

Smallpox and the development of vaccination

Severity of smallpox

In 18th-century Europe the chances of contracting smallpox in densely populated areas was one in three, death was assured to one in five and those who survived would often be left to suffer potential blindness and horrific scarification on their body. Between 1900 and 1979, smallpox is estimated to have killed between 300 million and 500 million people worldwide.

There are two clinical forms of the smallpox: variola major and variola minor. Variola major is a life threatening illness whereas variola minor is a milder infection that rarely caused death. It had a case-fatality rate of less than 1%, while variola major had an overall fatality rate of about 30%.

Smallpox symptoms and transmission

Symptoms such as fever, lethargy and sickness were common as the disease gestated within the body for seven to 14 days. Pustules broke out on the body, particularly covering face and hands and tended to ulcerate quickly, weeping pus. Eruptions within the mouth and nose seeped fluid down the throat.

Smallpox lesions scabbed over, so if the patient survived they could be badly scarred and the occurrence of the virus in the eyes meant the possibility of blindness even after recovery. The pustule phase was often very painful with sufferers known to have had their eyes sealed shut with pus.

It was during the pustule phase that the sufferer was at their most infectious to others. Smallpox patients were mostly cared for at home by family members, meaning constant exposure to the virus through airborne saliva and pus.


The established practice of variolation deliberately infected a healthy person with smallpox from the matter drawn from a pustule on a sufferer’s body. This allowed the healthy person to build immunity to the disease.

It is believed that this process has existed as far back as AD1000, practised by the Chinese who would insufflate (inhale through the nose) a powdered dried pustule.

In India, where historians believe smallpox originated from, the fluid would be mixed with rice or a sweet and ingested as part of a recovery process from inoculation performed on the skin.

Lady Mary Montague

When Lady Mary Wortley Montague lived in Constantinople in 1716, she became aware of a local practice performed with a half nut shell and a needle. This reportedly saved the locals from not only death but the debilitation and scarring of smallpox that she herself had endured.

On her return to England she championed variolation, advocating its use on her own children. The impetus for the adoption of this practice may have been the keen interest of the Princess of Wales, Caroline of Ansbach, following the suspected falling to smallpox of her youngest child in 1721.

The spread of inoculation

Variolation was also known as' inoculation' (from the Latin 'to implant') and both described the practice of cutting into the arm of a healthy person and smearing in the pus from an infected pustule.

Inoculation spread in Britain and across the world by wide publicity in the press. A new, milder form of inoculation which involved pustule lymph being placed into a shallow scratch was developed by surgeon Robert Sutton. He and his sons established a profitable inoculation business which treated over 300,000 people between 1762 and 1770.

Notably, the technique developed as a new weapon in the armoury of the doctors whom, seeking status and professional power, medicalised it and capitalised on its profitability.

However, the practice of inoculation was hazardous, as it could spark an epidemic within those who were not inoculated. Nor was it risk free – it could easily kill those it was attempting to protect.

Edward Jenner and cowpox vaccination

Edward Jenner’s 1797 discovery in Gloucestershire of using cowpox as a way of building a resistance to smallpox was named 'vaccination' after the Latin ‘vacca’ for cow. Despite troubled beginnings, vaccination swept through the world, becoming man's main defence against smallpox.

However, vaccination would still struggle against inoculation, which many refused to cease practicing. Anti-vaccination societies stalled vaccination progress and fought against legislation to make it mandatory.

Many utilised sensational ideas as propaganda to question the use of cowpox in vaccination. A cartoon by political satirist Gillray centred on the imagined dangers of vaccination by showing people turning into cows or growing cow parts following vaccination.

The evolution of vaccination continued with the introduction of specialised tools such as lancets and scarifiers to open the skin and introduce the animal material into the arm.

In addition, innovations such as preservatives and carriers – for example, lanoline oil, petroleum jelly and chloroform-laced glycerine – enabled the vaccine to be sustained during its distribution to the population.

Global eradication of smallpox

In 1959 the World Health Organization resolved not just to control smallpox but to globally eradicate it.

After an enormous campaign of vaccination, outbreak control and surveillance, the last case of naturally occurring smallpox was recorded in Somalia in 1977. The sufferer, Ali Maow Maalin, survived.

Several years earlier in 1972 the United States halted smallpox vaccination and in 1980 the World Health Organization published a recommendation that all countries should follow suit.

By 1986 routine vaccination in all countries across the world ceased entirely. Smallpox was apparently eradicated – only one of two diseases which humans have wiped out, the other being rinderpest ('cattle plague').

Back to top