Introduction: The practice of smallpox inoculation dates back to the 1500s in China and India. It became common in Europe, but was not utilized in the American colonies until the 1700s due to fear. The practice was successfully adopted during the smallpox epidemic in Boston in 1721. Over 50 years later, George Washington ordered mass inoculation of the Continental Army as smallpox was seen as a greater threat than the British Army.
Methods: A literature search was performed using Pub Med and Google on smallpox vaccination and the American Revolution.
Results: The city of Boston experienced a severe smallpox epidemic from the spring of 1721 to the winter of 1722. Over 6,000 cases and 850 deaths were reported in the population of approximately 11,000 people. Cotton Mather was a Puritan Minister who learned of smallpox inoculation (variolation) from his West African slave Onesimus, writing, “he told me that he had undergone the operation which had given something of the smallpox and would forever preserve him from it, adding that was often used in West Africa.” When the Boston smallpox epidemic arrived, he urged the medical community to inoculate the Boston community. Most physicians opposed the intervention based on religious grounds as well as scientific uncertainty. However, Zabdiel Boylston, the first American surgeon of the English colonies in North America (having performed the first operation for bladder stones and a breast tumor in the colonies) brought smallpox inoculation to the city of Boston. After demonstrating a reduction in death rate from 14.8% to 2%, many of the skeptics changed their opinion. Despite this experience in Boston and the experience with variolation in Europe, fear of the process remained. In 1776, the Continental Congress issued a proclamation prohibiting surgeons to inoculate the army. During the Revolutionary War, most British troops were immune to smallpox. In contrast, 90% of Continental Army deaths were due to disease with smallpox being the most common. In 1777, General Washington ordered mass inoculation of the Continental Army explaining, “Necessity not only authorizes but seems to require the measure, for should the disorder infect the Army...we should have more to dread from it, than from the Sword of the Enemy." Despite a lack of surgeons and supplies, the mass inoculation was successful. There were isolated infections, but no regiment was incapacitated.
Conclusions: Smallpox inoculation saved many lives all over the world. Mandated inoculation was essential to the successful victory of the American colonies during the American Revolution.
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