Smallpox vaccination in the early 19th century using live carriers: the travels of Francisco Xavier de Balmis.

Abstract: Realizing that the Spanish colonies were being devastated by epidemics of smallpox resulting in thousands of deaths, Charles IV, King of Spain, sent one of his court's physicians to apply the recently discovered vaccine. Without refrigeration, the vaccine was passed from one child to another (boys taken out of orphanages). Francisco Xavier de Balmis and a team that included three assistants, two surgeons, and three nurses sailed from Spain on November 30, 1803. They vaccinated more than 100,000 people from the Caribbean Islands and South, Central, and North America, reaching up to San Antonio, Texas, and then traveled to the Philippines, Macao, Canton, and Santa Elena Island, landing back in Cadiz on September 7, 1806. During his journey, Balmis instructed local physicians on how to prepare, preserve, and apply the vaccine, while collecting rare biologic specimens. On the 200th anniversary of their sailing, recognition is given to this group for conducting what was the first global vaccination campaign that reached Texas and California.

Key Words: history, live carriers, smallpox, vaccination

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Smallpox devastated the Spanish colonies periodically (Fig. 1); the most remembered event took place in 1797 when, in the vice kingdom of New Spain, 44,286 persons fell ill, of which 8,220 died in a period of 3 months. (1) The next year, Edward Jenner published Inquiry into the Causes and Effects of the Variolae Vaccine in London. Vaccination was first conducted among the royal houses of Europe; in Spain, Princess Maria Luisa had smallpox and barely survived. Her father, King Charles IV, urged by the Queen, ordered the vaccination of Princes Fernando, Carlos, and Francisco, who had low-grade fever for 3 days but did well. He also decided to make this benefit available to all his subjects in the Empire where the "sun never set" by first having the only book on the subject by J. L. Mareau de la Sarthe translated into Spanish by one of the Court's physicians. (2)

In 1802, the Viceroy of New Granada (Colombia) asked his Majesty for help after informing him of an epidemic of smallpox that had produced thousands of deaths. The Consejo de Indias, in charge of all issues related to the colonies, advised him to send an expedition to vaccinate against smallpox throughout the domain. The King decided on Francisco Xavier de Balmis, who had translated Moreau de la Sarthe's book. (3)

Born in Alicante on December 2, 1753, Balmis was the son and grandson of physicians. He graduated from the University of Valencia in 1775 and became a military surgeon in North Africa. He then traveled to Mexico in 1778, where he acted as director of the Amor de Dios Hospital and collected rare specimens of plants with medicinal properties, describing the healing action of the agave and a certain variety of Begonia named "begonia balmicensis" (Fig. 2).

A royal edict was issued to transfer 20 children between 8 and 10 years old from La Coruna's Orphans' Home; they were selected from those who had not had smallpox, and who had never been vaccinated before. Balmis' plan was to pass the vaccine live, transmitting it from child to child as the skin lesions began to extrude lymph from Days 4 to 10 postvaccination, preserving a drop in between glass slides that would be adhered by vacuum and sealed with paraffin. (4,5) The initial vaccination was performed in Madrid and carried on to La Coruna through sequential vaccination in five children from an Orphan House in Madrid.

Vaccination Sails Abroad

On November 30, 1803, Balmis' group--including assistants Jose Salvani, Manuel Julin Grajales, and Antonino Gutierrez y Robledo; surgeons Francisco Pastor y Balmis, Rafael Lozano Perez, and Basilio Bolanos; and nurses Angel Crespo and Pedro Ortega--boarded the corvette Maria Pita. (6) They reached the Canary Islands before Christmas, where they vaccinated hundreds of inhabitants and taught local doctors how to proceed. They sailed from Tenerife on January 6, 1804, and arrived in San Juan, Puerto Rico, on February 9. Although a program of vaccination against smallpox had already been started by bringing the vaccine from the island of St. Thomas, it had doubtful results; Balmis demonstrated that the vaccine had been made inert by improper handling. (7) On March 20, the group sailed toward La Guayra, Venezuela, where they separated into three teams: Salvani, Grajales, and Morales went to Bogota, Quito, and Lima; another team went to Cartagena and Caracas, where they vaccinated more than 12,000 people; and the rest sailed to La Havana, where nearly all inhabitants were vaccinated. (6)

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Vaccination in Mexico

By June 25, Balmis' team had reached Veracruz, sending two assistants and a nurse to Campeche and Merida. Another team traveled to Vistahermosa, then to Tapachula, and then to Guatemala City (8); every team took care to renew the vaccine in a new lot of children. Balmis himself traveled to Xalapa, Perote, and Mexico City. He wrote to the King complaining that he had not been provided with the seven carriages that he had asked for and about the lack of comfort in the house where he was hosted. He designed the posters for the vaccination sessions, requested a Tedeum Mass, and set up the "Vaccination Junta" that would plan the program for the whole country. (5,6)

Thereafter, he went north to Valladolid (Morelia), Queretaro, Guanajuato, and Guadalajara, vaccinating thousands, teaching the local physicians how to vaccinate, when to take the lymph, how to preserve it, and so forth. They continued to Durango, where Balmis commissioned Antonino Gutierrez to go to Baja California and then to San Diego and San Francisco in the "Alta California." (9,10) Balmis returned to Mexico City to prepare for the voyage to the Orient. In the meantime, he assigned Arboleya to go to Puebla, Tehuacan, and Oaxaca to vaccinate as many people as possible. A local group was commissioned to take the vaccine to San Antonio de Bejar, Texas. (11)

The "Nao" San Francisco de Magallanes was prepared for an ocean voyage (Fig. 3). Balmis ordered top-class accommodations and a compartment to store the vacuum machine as well as the barometric and thermometric instruments. He requested fresh meats, plenty of flour for bread, and 20 children for the transmission of the vaccine during the voyage. (5)

By this time, Balmis had developed impatience for incompetence, unjustified delays, and lack of preparation, engaging in quarrels with colonial functionaries and bureaucrats who called him the "Scientist Quijote." He sent back the original 20 orphans taken from La Coruna; however, the nurse that had accompanied them decided to remain with the expedition to care for the Mexican children that would carry on the vaccine. (6,12)

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Sailing to the Orient

They left Mexico City on January 14, 1805; five children were used to transmit the vaccine until they reached Acapulco. Finally, on February 1, they sailed toward the Philippines; the captain failed to provide the promised facilities and the food was terrible. The children slept on the floor in crowded quarters and accidentally came in contact with each other, with their arms producing unexpected skin lesions, which caused them to have elevated and prolonged fevers. However, all of them survived the ocean trip, landing in Manila on April 15, where more than 20,000 persons were vaccinated. (13) Balmis fell ill with dysentery, but on recovery he requested permission to go to Macao, and then assigned Antonino Martinez to return the children taken from Mexico.

On September 2, Balmis and Pastor sailed toward Macao, taking three children along for vaccination. They arrived 14 days later and began by vaccinating Governor Don Miguel de Arriaga and then most of the inhabitants of the island. They also traveled to the Chinese city of Canton, where the authorities reluctantly allowed Balmis to vaccinate all who requested it (approximately 600) (9). He instructed local physicians on the techniques of inoculation and preservation of the vaccine, collected botanical specimens, and took meteorologic measurements.

The return portion of the journey was made around the African continent, stopping at Santa Elena Island, which was then an English possession, on June 12, 1806. After Balmis convinced the governor, he vaccinated most of the inhabitants. Then, by way of Lisbon, the group landed in Cadiz on September 7, 1806. (4,9)

Conclusions

Passing lymph from a skin ulceration to another child may not be an acceptable method by today's standards, but at the time it was an ingenious and effective way to carry the inoculating fluid from one continent to two others when refrigeration, sterility, and asepsis were unknown. From California to Texas down to Guatemala, they vaccinated more than 45,000 of the 3 million Mexican inhabitants; over 14,000 in the Antilles; 26,000 in South America; more than 9,000 in the Philippines; and hundreds each in Macao, Canton, and Santa Elena. The "Vaccination Juntas" were an early example of voluntarism in a society where castes were still prevalent and slavery was concealed. Vaccination was instituted as a governmental function assisted and run by prominent citizens, teachers, clerics, and physicians. Records were kept of the individuals vaccinated; if the skin lesion failed, revaccination was recommended (Fig. 4). Since smallpox recognized no social strata, it affected rich and poor, soldiers and clergy, adults and children; it was, in a way, an equalizer. King Carlos IV's project had an unanticipated worldwide effect; it was started at the time when Napoleon's armies were invading Spain and Nelson was about to defeat the French and Spanish navies in Trafalgar. As such, it was a great disease prevention enterprise, headed by the controversial but diplomatic Francisco Javier de Balmis, who began the global eradication of smallpox that would take nearly 200 years.

[FIGURE 4 OMITTED]

If sunbeams were weapons of war, We would have had solar energy
centuries ago.
--Sir George Potts (Nobel Laureate)

Accepted February 17, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9704-0375

References

1. Cook SF. The smallpox epidemic of 1797 in Mexico. Bull Hist Med 1939;7:153-191.

2. Garcia del Real E. Historia de la Medicina en Espana. Madrid, 1921, pp 16-25.

3. Moreau (de la Sarthe) JL. Tratado Historico y Practico de la Vacuna. Traducido por Francico Javier Balmis; Madrid, Imprenta Real, 1803.

4. Lopez-Pinero JM. El Grabado en la Ciencia Hispanica. Consejo Superior de Investigacion Cientifica Madrid, 1987, pp 98-99.

5. Valdes U. Historia de la vacunacion en Mexico. Bol Dep Salubr Publica 1932: pp. 11-14.

6. Fernandez-del Castillo F. Los Viajes de Don Francisco Xavier de Balmis. Mexico City, Sociedad Medica Hispano Mexicana, 1985, 2a ed.

7. Quevedo Baez M. Historia de la Medicina y Cirugia en Puerto Rico. San Juan, PR, Asociacion Medica de Puerto Rico, 1949, vol I, pp 21-29.

8. Mastiney-Duran C. Las Ciencias Medicas en Guatemala: Origen y Evolucion. Guatemala City, Autor, 1956, pp 31-33.

9. Cook SF. Smallpox in Spanish and Mexican California 1770-1847. Bull Hist Med 1939;7:172-173.

10. Izquierdo JJ. Los Cuadros Murales de la Facultad de Medicina de San Francisco, California. Mexico City, Imprenta Universitaria de Mexico, 1942, pp 25-26.

11. Nixon PI. The Medical Story of Early Texas, 1528-1853. Lancaster, PA, Mollie Bennet Memorial Fund, 1946, p 100.

12. Vilchis-Villasenor J. Prevention of communicable diseases in Mexico: Part II. Smallpox [in Spanish]. Gac Med Mex 1971;101:144-153.

13. Bantug JP. Bosquejo Historico de la Medicina Hispano-Filipina. Madrid, Ediciones Cultura Hispanica, 1952, pp 110-112.

RELATED ARTICLE: Key Points

* Smallpox vaccination in the early 19th century was performed by inoculating small boys in sequence.

* More than 100,000 people in the Spanish colonies were vaccinated.

J. Antonio Aldrete, MD, MS

From the Arachnoiditis Foundation, Inc., Birmingham, AL.

Reprint requests to J. Antonio Aldrete, MD, MS, 938 Summit Place, Birmingham, AL 35343. Email: [e-mail]