By Paul Theerman, Associate Director

The recent death of physician and epidemiologist Donald Ainslie (D. A.) Henderson (1928–2016) brings to mind the heady days of the 1950s, ’60s, and ’70s. With the advent of vaccination, insecticides (for cutting down disease vectors), sanitation, and the full research armamentarium of microbiology, eliminating dread diseases once and for all, worldwide, seemed possible.  D. A. Henderson did that for smallpox. And in the collections of the Academy library, we have a small memento of that eradication campaign. The two-pronged (“bifurcated”) needle became the quick and easy vaccination device used to protect susceptible populations from that disease.

Bifurcated needle. Photo credit: Centers for Disease Control.

Here is Henderson’s recounting of the needle’s development, in about 1972:

D. A. Henderson (2nd from left) in Ethiopia administering a smallpox vaccine in 1972. Photo courtesy WHO, from “Donald D.A. Henderson, Epidemiologist who led WHO’s Smallpox Eradication Efforts, dies at age 87,” PAHO (Pan American Health Organization), accessed September 8, 2016.

I visited Wyeth laboratories …and they showed me this wonderful device which they developed. A little needle about ‐ well, about so long. There are two little prongs on the end. They called it a bifurcated or sort of two fork needle. The idea was you put the needle into the vaccine and you just withdrew it. Between those two prong[s], the little bit of vaccine would be held and then they thought you press it through the skin. In this way the amount of vaccine you could get from a vial was 100 doses rather than 25 doses. . . .We took it to the field into Kenya and Egypt and did several 100 children and we did it very vigorously. . .  Every single one of them was successful. So this was incredible. All of a sudden we were going to have four times as much vaccine than we thought we had or we are getting, with these wonderful needles.¹

In the course of the smallpox eradication campaign, public health workers used needles such as this to vaccinate millions of people—the goal was 80% of the population. In 1979, the World Health Organization declared that natural endemic smallpox had been eliminated from the globe.²

This was a great feat. Smallpox has been infecting humans since before recorded history. It was so virulent, especially among the inhabitants of the new world, that providing smallpox-infected blankets to Native Americans during the French and Indian War of the mid-1700s became one of the first examples of biological warfare.³ Famously, in the late 18^th century, Edward Jenner found that cowpox could be used to vaccinate against smallpox, and in the western world, cases subsided thereafter.

In the developing world, smallpox was still endemic and often fatal. Prior to its eradication, smallpox killed nearly 300 million people world-wide in the 20^th century alone.⁴ And those who survived carried disfiguring scars.

The decision to mount a world effort to eliminate smallpox was not taken lightly. In 1966 the World Health Organization took up a funding proposal for a smallpox eradication campaign. Four other efforts had already failed: hookworm, yellow fever, yaws, and malaria.⁵ Public health officials were beginning to think that eradication campaigns were too expensive, too time-consuming, too technically-challenging, and too “top-heavy”– the externally mandated efforts pushing aside the building up of public health infrastructure in developing countries. Nonetheless, WHO narrowly passed the ten-year, $24M plan. Henderson had had a role in drafting it: some years before, in charge of the surveillance section at the Centers for Disease Control in Atlanta, he had played a role in adding a smallpox vaccination program to a fledgling measles vaccination program for West Africa, funded through the U.S. Agency for International Development (USAID). Thus he already had practical experience in mass smallpox vaccination, and after the WHO passed their plan, he was named to head the effort.

According to Michael Oldstone:

Henderson used two principal strategies. First, international vaccine testing centers were developed to ensure that all vaccines met the standards of safety and effectiveness. This guaranteed that only active vaccines would be used. Second, reducing the number of smallpox cases to zero became the established goal rather than documenting the number of vaccine doses given. With this goal, effective surveillance teams were set up to both report and contain outbreaks of smallpox.⁶

Success was beyond expectation. As Henderson recalls:

About 4–5 years into the programme, we had begun thinking that eradication within another 3–4 years might be feasible. The West African programme had proceeded so well and so rapidly that it stunned everyone. Most of East Africa also became smallpox free only a few years later. From 1967 to 1973, the number of smallpox endemic countries dropped dramatically—from 31 to only five—India, Pakistan, Bangladesh, Nepal and Ethiopia. South Asia was a formidable problem. . . .⁷

World Health: The Magazine of the World Health Organization (May 1980), cover.

The WHO effort finally eradicated smallpox in these few remaining countries. “In 1975 [smallpox was eliminated] from the entire Asian continent, in 1976 from Ethiopia, and in 1977 the last case was reported in Somalia [having spread from Ethiopia].”⁸ For two more years, surveillance continued, with rewards offered for reports of active cases. None was found. WHO set up a Global Commission to review the reports, and on December 9, 1979, certified worldwide eradication. Smallpox was gone.⁹

Henderson attributed his success to three factors: “surveillance-containment, . . . a heat-stable vaccine of assured potency, and a better technique for vaccination.”¹⁰ Oldstone had noted the first two, but clearly Henderson felt the third was just as important, the bifurcated needle!¹¹

Our needle came into the collection quite recently. In 2010 Dr. Henderson gave a lecture at the Academy, for the Malloch Circle of the Friends of the Rare Book Room.¹² At the conclusion of his talk, Dr. Henderson asked if anyone would like a smallpox vaccination needle to keep.¹³ Historical Collections Librarian Arlene Shaner claimed one for our collections. It remains a symbol of that eradication campaign—a testimony to the possibility of global effort achieving enduring relief from suffering and death from smallpox.

The Academy’s smallpox inoculator. The needle is 2 inches (5 cm) long.

References

1. Paul O’Grady (Interviewer), “DA Henderson Oral History,” The Global Health Chronicles, accessed August 29, 2016, pp. 10–11.
2. D. A. Henderson, “A victory for all mankind,” World Health: The Magazine of the World Health Organization (May 1980), pp. 2–4.
3. Michael B. A. Oldstone, Viruses, Plagues, and History, revised and updated ed. (New York: Oxford University Press, 2010), p. 53.
4. Oldstone, Viruses, Plagues, and History, p. 53.
5. Henderson DA, Klepac P., 2013, “Lessons from the eradication of smallpox: an interview with D. A. Henderson.” Phil Trans R Soc B 368: 20130113, accessed August 29, 2016.
6. Oldstone, Viruses, Plagues, and History, p. 83.
7. Henderson and Klepac, “Lessons.”
8. Oldstone, Viruses, Plagues, and History, p. 84.
9. Henderson, “A victory for all mankind,” pp. 2–4.
Not entirely gone: stocks of smallpox virus remain for study. In December 2002, the U.S. Government began smallpox vaccination for select military personnel to protect against biological attack. John D. Grabenstein, RPh, PhD; William Winkenwerder, Jr, MD, MBA, “US Military Smallpox Vaccination Program Experience,” JAMA. 2003;289(24):32783282. doi:10.1001/jama.289.24.3278.
10. Henderson and Klepac, “Lessons.”
11. Though eradication has a strong public appeal, the smallpox project was more the exception than the rule. Henderson remained quite skeptical of other proposed eradication efforts, notably those for polio. He went into some of his reasons in Henderson and Klepac, “Lessons.”
12. The New York Academy of Medicine, 2010 Annual Report (New York: The Academy, [2011?]), p. 13.
13. It seems a curious practice. The only thing similar of which I am aware is the military habit of “coining”: where superior officers mint commemorative coins that they dispense to colleagues and those lower in the ranks as a sign of approval for work done. As head of the quasi-military Commissioned Corps of the U.S. Public Health Service, Surgeon General C. Everett Koop followed a similar practice. John S. Halamka, “The Tradition of Coining,” Life as a Healthcare CIO, April 17, 2008, accessed August 29, 2016.

Professor Anita Guerrini, Horning Professor in the Humanities at Oregon State University, wrote today’s guest post.  It was first published on the author’s site, anitaguerrini.com. Next Tuesday, September 13th, 6:30pm, Dr. Guerrini will give a talk at the Academy Library, “Animals and Humans in Louis XIV’s Paris.”   Registration is required in advance ($35 for Friends of the Rare Book Room; $50 for the general public, with wine and refreshments).  You’ll find registration and more about the event here.

On the 12^th of May, 1543, Jakob Karrer von Getweiler was executed in Basel, Switzerland. Reports say he was beheaded, although hanging was a more usual mode of execution. Karrer was a bigamist who attacked his legal wife with a knife after she discovered his second wife. According to a contemporary account, Karrer was a habitual criminal, and he left his wife grievously injured. Although she did not die, he was sentenced to death.

The frontispiece of Andreas Vesalius’ De humani corporis fabrica libri septem, published in 1543.

The renowned Flemish anatomist Andreas Vesalius had been in Basel for several months to supervise the publication of his magnum opus, De humani corporis fabrica libri septem (Seven books on the structure of the human body), published there later that year.

Perhaps it was inevitable that Vesalius was granted Karrer’s body to dissect. Only executed criminals could be publicly dissected, with the blessing of the Basel Senate. We do not know if the Senate offered Vesalius the beheaded body or if he requested it. But Vesalius dissected Karrer, in front of an audience.

A historiated initial showing a decapitated head being passed down from a scaffold, published in de humani corporis fabrica (1543).

Vesalius then took Karrer’s dissected remains with the intention of making an articulated skeleton. In chapter 39 of Book 1 of De Humani Corporis Fabrica, the anatomist had detailed for the first time the lengthy and gruesome process of constructing a skeleton. He included this illustration of someone handing down a decapitated head from a scaffold.

Some of the techniques had existed for quite a while; the 14^th century physician Guy de Chauliac noted “Nous faisons aussi l’Anatomie [d]es corps desseichez au Soleil, ou consommez en terre, ou fondus en eau courante ou bouillante”¹ (we make an anatomy of bodies dried in the sun, or consumed by the earth, or dissolved in running or boiling water – “an anatomy” here indicates a skeleton). Macerating in water and then drying in the sun were long-known methods of preparing bones for transport.

In his chapter, Vesalius first described the conventional method of preparing a skeleton, and illustrated it in one of the initial letters in his book. As much flesh as possible was cut off of the body – without severing the joints or the ligaments – before it was put in a long perforated box, covered with quicklime, and sprinkled with water. After a week the box was placed in a stream of running water and the flesh would presumably fall off of the bones and be washed away over a period of several more days. Then the body was removed from the box, further cleaned with a knife, and posed in the sun to dry in a particular position, held together by its ligaments.

Vesalius described this method only to denigrate it as time consuming, dirty, and difficult; moreover, the blackened ligaments would cover the joints and other parts of interest. He proceeded to describe in excruciating detail the proper way to separate human bones from flesh. “Get any kind of cadaver somewhere,” he began. The corpse was dissected and then boiled “in a large and capacious cauldron … of the kind women use for the preparation of lye over the fire.” He saved the cartilaginous parts such as the ears and stuck them to a piece of paper, and placed the organs and blood (squeezed out of a sponge) in another vessel.

The bones were boiled, carefully covered by water at all times, for several hours, with regular skimming off of froth and fat. The bones of children, he said, take less time than adults. “The object of the cooking is to clean the bones as thoroughly as is done with the knife while eating.”

Historiated initial in Andreas Vesalius’ second edition of de humani corporis fabrica, 1555.

Therefore one should pull out individual bones from the “broth” with tongs from time to time and clean them further with the hands or a knife, but this job should not be entrusted to a mere amateur. The knives he used were similar, if not identical, to the knives wielded by such master meat-carvers as Vincenzo Cervio later in the sixteenth century, and the language of cooking is explicit. One then placed the cleaned bones in more boiling water, and finally removed them, carefully drying them with a rough cloth to remove remaining bits.

Bone drill, published in Andreas Vesalius’ De humani corporis fabrica, 1555.

The bones should not be allowed to dry too much. If they are not too hardened, a shoemaker’s awl may be used to punch holes for the copper wire used to string the bones together, although in his 1555 second edition Vesalius also described a bone drill he had constructed.

He recommended starting with the feet and working upward, the reverse of the common head-to-toe order of dissection. An iron rod, made to order, supported the vertebrae; the arms were then assembled and wired to the trunk.

With characteristic macabre whimsy Vesalius recommended posing the skeleton with a scythe, or a pike, or a javelin, and suggested stringing the ear bones and ears onto a nerve to make a necklace (when I read this I could only think of Tim O’Brien’s surreal story “The Sweetheart of Song Tra Bong,” in The Things They Carried (1990), and its heroine Mary Anne who wears, at the end, a necklace made up of severed Viet Cong ears).

The skeleton of Jacob Karrer, unlike most others from this era, still survives, and is on display at the anatomy museum in Basel, where I saw it a few months ago.

Skeleton of Jakob Karrer, Anatomisches Institut der Uni Basel. Photo Credit: Anita Guerrini.

We hope to see you at Dr. Guerrini’s talk next Tuesday, September 13th.

References

1. La grande chirurgie de Guy de Chauliac. Paris: Alcan, 1890.