The Introduction of Smallpox Vaccine in 1803 and the Adoption of Immunization as a Government Function in Puerto Rico

The yelling could be heard in the Street, two floors down. Young soldiers rushed up the stairs, in Order not to miss the action, while other witnesses nearby must have wondered why one physician had not yet thrown the other off the balcony. “One hundred sixty thousand persons in Puerto Rico all know about this affair, it has been so public and scandalous.”¹ A king’s physician, the royal commissioner, was publicly insulting the city doctor, the man who had brought smallpox vaccination to the island! It had been the Spanish king’s intention that the first arrival of vaccine to his American and Asian colonies would be due to a Royal Philanthropic Expedition, directed by the renowned physician and botanist Francisco Xavier de Balmis.² Nevertheless, the widespread fame of the method, a desperate need for its life-saving effects, its availability in nearby non-Spanish locations, and the resourcefulness of colonists served to anticipate the expedition’s task in the Caribbean.

The analysis of this episode is important because Puerto Rico, Balmis’s landfall in America, was also the focus of dissemination of vaccine to the Spanish Caribbean before the expedition’s arrival. Balmis’s reaction was to denounce the vaccinations carried out on the island as useless, and their perpetrator as a fraud. This produced an irate rebuttal from officials in Puerto Rico. The documents in which these allegations are preserved describe vaccine distribution in a context of economic, political, and personality conflicts that directly affected the manner in which vaccine was offered to the island’s population.

In 1798, Edward Jenner published An Inquiry into the Causes and Effects of the Variolae Vaccinae in London, describing how injection of fluid from cowpox pustules protected the subject against acquiring smallpox. His discovery spread with surprising rapidity in a Europe that was beginning the long years of the Napoleonic Wars. In America, where smallpox had caused catastrophic epidemics among natives at the beginning of colonization, and then severe mortality among all inhabitants in the succeeding centuries, vaccination was first used in Newfoundland. The lymph had been sent by Jenner himself, soon after 1798, but the method did not spread further. However, Benjamin Waterhouse, in Massachusetts, performed a successful vaccination on his son in July 1800, with lymph sent from England. As a result of Waterhouse’s collaboration with President Jefferson, lymph fluid was introduced in 1801 in Washington and Philadelphia, and then was sent to Baltimore and New York.³

Jenner’s work was first publicized in Spain as an abstract in the Semanario de Agricultura y Artes in March 1799. Dr. Francisco Piguillem, in Puigcerdá (Catalonia) is credited with the first vaccinations (December 3, 1800), using fluid he received from Paris. Most of the early proponents of vaccination in Spain also received the fluid from Paris, as well as French scientific publications on the subject.⁴

The fluid was transported in different ways. It could be vacuumsealed, pressed between two glass slides, or impregnated in threads and then dried. But the most successful method was arm-to-arm transmission: vaccinating the subject with fresh fluid from someone else’s pustule at the peak of reaction. The cowpox matter was introduced into the recipient’s arm by repeated superficial incisions of the skin with a lancet or needle. In three or four days, a raised patch of skin was noticeable, surrounded by a reddish zone. The patch slowly became a fluid-filled bleb, which reached maximum size by day 10. The fluid in the vesicle turned from clear to purulent, and the surrounding skin reached a peak of reaction at days 10 and 11, after which the pustule would develop a dry crust at its center. By day 14, it was a brownish scab that sloughed leaving a circular scar. Fluid from the vesicle at day 9 or 10 was used for propagating the vaccine.⁵

In 1803, Spain’s government was unsuccessfully attempting to disengage from the commitments to Napoleonic policy that would eventually lead to the defeat at Trafalgar (1805), and later the French invasion (1808). Nevertheless, the report of a smallpox epidemic in Bogotá prompted King Charles IV to ask his Council of the Indies in March of 1803 to evaluate the possibility of taking the vaccine to the colonies. The council was already considering the problem, and through spring and summer of 1803 different plans for the organization of the expedition were considered. The detailed proposal by Dr. Francisco Xavier de Balmis was accepted with only minor changes, and he was appointed director of the expedition. Then age 50, Balmis was well qualified for the post. He had served in the army and the navy, had been in Mexico and Cuba several times since 1781, and was honorary physician of the King’s Chamber. He had trained as a surgeon in Valencia (1778), and years later was granted a doctorate in medicine. While in Mexico he conducted studies on the antisyphilitic properties of plant concoctions, and in Madrid he had quickly adopted the practice of vaccination, becoming one of its leading practitioners. In 1803, he published a translation of the Traité historique et pratique de la vaccine by J. L. Moreau de la Sarthe (originally published in Paris, 1801).⁶

On September 1, 1803 a royal Order was sent to all jurisdictions of the empire, describing the mission of the Royal Expedition of the Vaccine, and giving specific instructions for its reception. The expedition would sail from La Coruña and stop in Tenerife (Canary Islands), Puerto Rico, and Havana. At a convenient time, the expedition would divide. One group would take the vaccine to South America, and the other group (under Balmis) would go to Mexico, Guatemala, and if possible, the Philippines. A sufficient number of children would be vaccinated in succession throughout the voyage, so that arm-to-arm transmission of the fluid could be performed on arrival at the Indies. Copies of Balmis’s translation of Moreau’s book were to be distributed to physicians in the colonies. The royal Order did not give clear instructions on the towns’ obligations for funding the expedition (an oversight which later caused endless aggravation), and they made no mention of the size of the group accompanying Balmis.⁷

The expedition left La Coruña on November 30, 1803, in the 160-ton corvette María Pita, commanded by Lieutenant Pedro del Barco.⁸ The group included Balmis, José Salvany (his deputy), two other physicians, three practitioners (assistants to the physicians), three male nurses, a secretary, some servants, 22 children (three to nine years of age), and the former rectoress of the Coruña foundling house. Two children were vaccinated every ninth or tenth day of the voyage, so that the chain of vaccinations was carefully maintained.⁹

The embarkation of nearly two dozen children on a transatlantic crossing in time of impending war was a humane endeavor, compared to the prevailing treatment of foundlings. Most abandoned newborns were subject to brutal conditions before arriving at an asylum. Except for the fortunate few left at the doorstep of the institution, newborns were left on church steps or private doorways, then given to whoever could be found to go to the town where the asylum stood, even if the trip (maybe in a basket with other babies) could take several days. Many infants died before arrival; some were noticed to be dead only at arrival.¹⁰ Even with such great mortality before admission, and the royal interest at this time in the preservation of foundlings, the average mortality rate for the first year of life of those brought to the Santiago de Compostela Royal Hospital Foundling Asylum in the period 1800-1804 was 741 per 1,000.¹¹ Presumably, most of these deaths occurred outside the Institution, because after acceptance in the asylum the children were fed, clothed, and, a few days later, sent back out, this time to a foster family in a village in the region (but up to 40 kilometers from Santiago). Breastfeeding and raising the children were unpopular Services that the village women were forced to offer for a very modest salary. The pay decreased after two years (when weaning was supposed to occur), and ended when the child was five years old. At that time, many (of the few surviving) children were adopted by their foster parents, but others were returned to the asylum, which then discharged them, leaving them to their own devices.¹² Inclusion in the expedition, which provided the opportunity to come under the king’s special protection, must have seemed a godsend for these foundlings.

The governmental institutions served Balmis very well. On August 16, the king ordered the foundling homes of Madrid, Santiago de Compostela, and La Coruña to provide Balmis with children who had not suffered smallpox, and the chain of arm-to-arm passage of vaccine was started in Madrid. On October 20, Balmis wrote to the archbishop of Santiago to request foundlings who had not experienced smallpox infection. The asylum’s administrator quickly had lists made of male foundlings four to eight years of age billeted in nearby parishes. “Commissioners” were sent to tell foster parents to bring the qualified children to Santiago. Forty-seven boys eventually showed up, some of them having already had smallpox, and a large number too late for selection. On November 8, a surgeon of the hospital, acting on Balmis’s behalf, chose only five children, because the expedition’s director had found others elsewhere (presumably in the Coruña foundling home, a branch of the Santiago institution). The five boys, aged four to six and a half years, were surrendered to the king’s protection, because the royal order promised that the foundlings taken to America would be educated there at the government’s expense, and then given employment. The foster parents of these five children received a compensation of 12 to 40 reales, depending on the distance traveled to bring the child in. A similar stipend was given to the foster parents of foundlings who were not considered suitable for the expedition, and even to those who came too late for the children to be examined.¹³

The expedition arrived in Tenerife on December 9, 1803. Public vaccinations were immediately started, and a vaccination house was founded, to be administered by a board which was to watch for the Conservation and propagation of the vaccine fluid.¹⁴ On December 14, Balmis took care to write to the governor of Puerto Rico, the next stop in the voyage, to alert him that the expedition would probably arrive there by the end of January.¹⁵ The María Pita left Tenerife on January 6, 1804, and arrived in San Juan on February 9. A representative of Governor Ramón de Castro welcomed the visitors, and after the usual formalities, Balmis was immediately told that the vaccine had been introduced in San Juan two months before.¹⁶

Puerto Rico had undergone catastrophic smallpox epidemics in 1518, 1689, and 1792, and smaller outbreaks in 1528-30, 1597, 1623-24, and throughout the eighteenth Century.¹⁷ Inoculation of the disease was first used in Puerto Rico as a preventive measure in 1792, by Francisco Oller, a military surgeon who had finished studies at the Barcelona Royal College of Surgery in 1780 and arrived in San Juan in 1790. By 1803, Oller was chief surgeon of the Royal Military Hospital, surgeon of the royal prison, and physician of the Hospital de la Caridad; he had been in charge of medical Services during the siege of the city by the English in 1797, and had been consulted by bishops, governors, and important officials for personal and public health matters. In 1798, he received, by royal Order, a doctor’s degree in surgery and medicine from the College of Cádiz.¹⁸

In November 1803, Puerto Rico was going through another smallpox epidemic. The infected were taken to an isolation hut outside of town. The mothers’ cries, on being forcibly separated from their affected children, regardless of night or rain, moved even the municipal clerk to reflect on the apparent lack of charity and justice of the procedure, but its necessity for the preservation of the general good.¹⁹ Oller knew of Jenner’s discovery and had heard that it had been taken to the neighboring island of Saint Thomas (present-day U.S. Virgin Islands). He wrote to an acquaintance there, a Dr. Mondeher, who on November 14 sent threads impregnated with dried vaccine lymph. The injections performed using this material had no effect. On November 23, Mondeher answered Oller’s second request with vaccine fluid conserved between glass slides. Oller vaccinated two of his sons, Genaro and José María, on November 28, and the Operation was successful in the latter. Six days later, when the vaccine pustule showed a “beautiful areola,” Oller presented the child to the governor, who, “full of joy,” entrusted the doctor with establishing the necessary procedure for general vaccination.²⁰

On December 7, Governor Castro notified the San Juan municipal councillors that vaccination had been successfully established in the city, and that he had charged Oller and Tomás Prieto (another army physician) with propagating the vaccine.²¹ At the same time, he informed them of the royal order of September 1, 1803 which announced the vaccine expedition. Castro asked the cabildo’s opinion on what efforts should be made to immediately propagate the vaccine in San Juan, considering the mission of the royal expedition. As Castro expected, the cabildo endorsed immediate use of the vaccine fluid in the town, especially since the expedition might not arrive as soon as it was needed in the current epidemic. A furnished house (“of the late Miguel Xiorro”) was made available to Oller and Prieto for the propagation of the fluid, and Councillor Juan Antonio Mexía was given authority to act for the city in all that was needed. The cabildo noted that “the physicians’ salaries would be determined after observing the care and zeal they put in their work.” The very large house was chosen so it could also serve to lodge the expedition when it came. The governor agreed with all, and notices were posted, announcing that public vaccinations would be performed in the appointed house every morning from ten to twelve, starting on December 17.²²

In the meantime, Oller, using lymph from José María’s pustule, had vaccinated 4 of his children, and 12 others. Tomás Prieto, the chief physician of the military hospital, had vaccinated his daughter, and Oller’s son (José María?) had vaccinated his mulatto servant.²³ With the lymph of these 18, a solemn inaugural immunization session was held in the house of vaccination on December 17, with the governor, the bishop-elect, the municipal council, and other high-ranking civil and military officials in attendance.²⁴ Several days later, the governor of Saint Thomas answered Castro’s request for more lymph, sending the fluid to Puerto Rico on glass slides and, to make sure the vaccine arrived, on the arm of a recently vaccinated infant slave girl. In addition, a Dr. Meyer sent lymph pressed in glass slides.²⁵

How did vaccine get to Saint Thomas? The British occupied the (then) Danish Virgin Islands, including Saint Thomas, from 1801 to 1802. Although vaccination had been introduced generally in the British army and navy in 1800, as late as November 20, 1800, black recruits in the army in the Caribbean were being inoculated with smallpox (not vaccinated) so that they would not contract the infection by natural means.²⁶ Since vaccination was made compulsory in the army in 1802, it is very possible that English vaccine came in the wake of war.²⁷ But one must also consider that in 1802 the Danish Royal Institute for Vaccination sent 16 “lots” of vaccine to the West Indies, which suggests that vaccine was still not to be had there.²⁸ The lymph had unquestionably arrived by February 17, 1803, because a newspaper advertisement published the next day in Saint Croix announced free vaccinations for the poor.²⁹ In view of the constant commercial traffic between San Juan and Saint Thomas, and the speed with which vaccine was spread throughout the Spanish Caribbean after it reached Puerto Rico, it is surprising that the Jennerian method took at least nine months to arrive in San Juan from the Danish islands.³⁰

On December 21, Castro informed Spain of the events in Puerto Rico. Among the first people to be vaccinated were his two daughters. Indeed, the vaccinations were undertaken with great enthusiasm: 1,557 persons were vaccinated from December 17, 1803 to February 9, 1804. The procedure became such a fad that children, at their games in school, vaccinated each other.³¹

On January 16, Castro received Balmis’s letter from Tenerife and forwarded it to the cabildo, warning that everything should be ready without fault so there would be nothing to cause grievances or bad feelings. With that, the discussions started among the councillors. Should the city pay both for the house and for the care and feeding of the children? The economic Situation of the island was precarious. Through the eighteenth Century the island’s government relied on a subsidy (situado) assigned to Puerto Rico by the crown from the treasury of New Spain. No subsidy came from 1799 to 1809.³² There were no funds to cover the ordinary expenses of government, so that its employees and the troops had been at half pay since June 1803.³³ It is easy to see why some councillors were disgruntled at being made to pay for an expedition that would not bring any benefits by the time it arrived, especially when their thriftiness could have been excused by mentioning that it was expressly forbidden in the Laws of the Indies for municipalities to spend any of their own money (fondos de propios, derived from tolls, public property, and municipal fees) on receptions, dinners, or lodgings for the reception of any official.³⁴ Nevertheless, the majority vote, as announced to Castro on January 27, was to offer voluntarily to have the house ready and take care of the children.³⁵

As soon as the arrival of the María Pita was announced in San Juan on February 9, 1804, the governor ordered a delegation, formed by Mexía, another councilman, and the municipal clerk to greet Balmis, bring him and some children to land in the “king’s boat” or official barge, and accompany them to the house prepared for their lodging.³⁶ A little later, Castro welcomed Balmis and his staff personally at the governor’s palace (La Fortaleza), and an hour and a half after that Castro went to visit the vaccination house, where he talked to the children. On saying farewell, Castro invited Balmis to come see a comedia casera that evening (literally a domestic comedy, probably an amateur production or perhaps a play reading), but Balmis declined the invitation, on account of being tired.³⁷ Nevertheless, the municipality held a banquet that evening in honor of Balmis and his staff.³⁸ It was carnival season anyway, and the entire city was in a festive mood.

At some time during the first day’s activities, there was an exchange of letters between Balmis and Castro, with the former announcing his arrival, and the latter indicating that the expedition’s director would not have much to do in Puerto Rico, because a large number of people had been vaccinated in the island as a protection against the smallpox outbreak that had been detected in San Juan. The following day Balmis answered that he would, indeed, find much to do, since his mission was “not only to bring vaccine, but to assure its perpetuation, which is the hardest [task].” He sent Castro 12 copies of Moreau’s book, announced the first vaccination for the next day (Saturday, February 11) at 10 a.m., and asked the governor to order all physicians and surgeons to be present.³⁹ Balmis then complained in writing to the governor that the accommodations for the expedition were not adequate, especially that cots had no mattresses, sheets, or pillows. Castro, by letter, reprimanded the municipal council and the councilman in charge of preparations.⁴⁰ Mexía explained that he had taken great care to prepare house, kitchen, and cots for 21 children and 7 other persons, but that mattresses, sheets, and pillows were considered to be a regular part of a ship’s baggage so he had not thought to provide them. The large number of people in the expedition was unexpected, but Mexía that night gave Balmis the keys to another large house; nevertheless, “as they had no servants who would cook for them, it seems not to have suited them.” Mexía found them servants, and lent them two large mattresses and some sheets of his own, not looking for more because when he came with these he noted that, by order of the governor, sheets had been provided from the royal hospital.⁴¹ The children and their governess, Balmis, and the other companions were provided with cooks, lights, and firewood, and even refreshments that they requested in the afternoons. The children all received new clothes, because the voyage had spoiled their old ones. All of this was done at no cost to the members of the expedition, and some of them even lived in other houses in the city at the expense of their hosts.⁴² To make sure the expedition would lack nothing, the municipal council named an additional commissioner (José Sánchez Bustamante) in spite of Mexía taking offense.⁴³

That same day, Castro visited Balmis and watched the children have lunch. The captain-general noted that on this second visit Balmis took even longer than the day before to come out and greet him, and again did not offer him a seat. Balmis did not thank him for having arranged the free lodgings of the director’s assistants in private homes, and, finally, had the discourtesy (grosería) to send the children to their room when they started to kiss the governor’s hand after their meal was finished.⁴⁴ Thus, in 24 hours Balmis managed to offend and embarrass both the governor and the municipal council, but in spite of these and other frictions Castro had Balmis and Salvany at his mansion for dinner.

Balmis held public vaccination sessions on February 12, 20, 21, 28, and 29.⁴⁵ For the first few days, Drs. Oller and Balmis treated each other with great closeness and familiarity, as Mexía later described. Oller lodged Salvany in his home from the first night and even attended him during an illness, and, according to Mexía, one could hear it publicly said that the city physician would be well recommended to continue in charge of vaccinations.⁴⁶ Nevertheless, on February 14 Balmis wrote to Castro mentioning his suspicions that the vaccine spread in San Juan before the expedition’s arrival was “false” (ineffective). Balmis had heard that a young man had died of smallpox in the town of Fajardo. As the vaccine could have been false, he requested that all facultativos (physicians and surgeons) send him a description of how and where vaccinations were conducted and how many were vaccinated, and that tenientes a guerra (military officers in command of towns) should report any occurrence of smallpox. Once informed of this, he would “fly to stop immediately the smallpox contagion in Fajardo.” He also commented on how he was displeased that vaccine had been propagated in Puerto Rico.⁴⁷

Castro answered that, indeed, Francisco Pacheco y Normandía had died of smallpox in Fajardo on February 1st, but unvaccinated, because the method was not yet in use everywhere. To distribute vaccine throughout the island, Castro had ordered each of the principal towns to send a facultativo to San Juan with two or three healthy boys who had not suffered smallpox. The children would be vaccinated, the medical Professionals would be instructed in the method of arm-to-arm vaccination, and on return to their town they would take the lymph to the smaller townships.⁴⁸

Castro must have asked Oller to respond to Balmis’s Statements, because on February 15 (Ash Wednesday) Oller sent Castro a report of how he had vaccinated 1,557 persons in 29 sessions. The report was forwarded the following day to Balmis, who answered that Oller vaccinated as initially performed in Europe, so that his vaccinations showed “infinite anomalies.” Oller then responded (to Castro) that one of his reference texts was as recent as 1802, and that he tested two boys (one of them his son) by smallpox inoculation after they had recovered from his vaccination, and neither of them acquired the disease.

Two days, and several letters, later (February 18), Castro was growing impatient, and he asked Balmis to formally decide if Oller’s vaccinations were or were not good, so that posters could be put up notifying the 1,557 vaccinated that they needed revaccination. Balmis then answered with a collection of galling statements that made Castro furious. Balmis’s letter stated that, “lacking as Your Lordship is in these lights [medical training], it would not be easy to make myself understood, as high as your penetration might be.” Prieto’s vaccinations were “the most empiric” ever made, but Balmis had heard of how Castro “thanked Prieto publicly after witnessing his clumsy operations,” of which “thank God” he only made three, because he started on December 17 and died the 21st. As for Oller, he vaccinated very differently from the staff in the expedition, so the involuntary error must be announced, and Balmis would begin public training for facultativos on February 20. He ended expressing his sorrow that he had not pleased Castro as he had pleased the governor of the Canary Islands, “as shown in the enclosed letter” (in which the Marqués de Casa Cagigal expressed his hope that Balmis would find an artist who would “make eternal your memory perpetuating the remembrance of your commission”).

Before answering Balmis, and before publicizing the vaccination “error,” Castro wrote to inform Bishop-elect Arizmendi. The latter (who had received vaccine lymph from the pustule of one of Castro’s daughters) advised the captain-general to follow Balmis’s recommendations, because of his “important most grave commission,” because the two of them could not “pass judgment on an issue whose hidden secrets have made even professors err,” and because otherwise serious consequences might follow. “What in my opinion is important is that we omit discussions and we all work in agreement so that the public will be served as the king wills. . . . I want to be the first to be revaccinated, so that with my example the rest will be more easily persuaded.” Castro then wrote to Balmis, offended at the director’s reproach for his lack of medical education, “which could have been omitted, although it is true.” He noted that Moreau, in his prologue, said that with average talent, even if one knows no medicine, one could form a correct idea of vaccination. Although Castro had never contradicted Balmis’s medical opinions, he defended Prieto and told the director that the expression of thanks to God for Prieto’s death was im-proper. Balmis then (February 20) requested a certified list, specifying dates, of everyone vaccinated before his arrival.⁴⁹ On that date he presumably started his public Conferences. The little we know of Balmis’s training sessions is contained in the deposition of Juan Antonio Dorado, regimental surgeon. Asked on February 28 about Oller’s vaccinations, he testified that in Oller’s and in Balmis’s sessions there had been good and bad vaccine, which he learned to distinguish because of the book he received from the director, and by the “long Conferences” that Balmis gave “chair-to-chair to make us physically see that all the wit of this great work consists in getting to know when the vesicle is ripe.”

On February 21, Oller went to the vaccination house to find Councilman Mexía and give him a message from the governor. A short time later, Balmis appeared, as Oller describes it,

Such a greeting, Oller continues, would surprise the most sane and patient man, especially “if one remarks that between the director and me there is no more essential difference than the honors with which our august sovereign has decorated him.” Balmis produced Oller’s letter to Castro of the day before, stating under oath the number of vaccinated and how vaccine was sent to Yabucoa. Yelling at Oller and all those present, Balmis said that Oller had sworn falsely, that he lied in that letter, that he was a flatterer of the governor, that everything Oller said was false, and that vaccine had been sent nowhere. Oller later described how he resigned himself to suffering this abuse, only defending himself in what he thought most convenient to the circumstances, without exasperating Balmis any further, but that the director repeatedly called him “ignorant, and other insults that I commit to silence.” Balmis told Oller that he would see the result [of his dealings] in four months, and that no one had vaccinated so clumsily as he had. Oller brought up his sources of Information, but Balmis said they were worthless pamphlets. When the director turned his back on Oller, the city physician left, in great consternation.

This scene provoked Oller to write to the king to ask for recognition of the correctness of his procedures. Witnesses of the altercation were interviewed for their description of the event. Councilman Mexía testified, in a deposition that Oller found vacillating and equivocal, that the Catalan physician had arrived in the house of vaccination as he was accustomed to do at all hours of the day and early evening, and had greeted Mexía who was entertaining the children, when Balmis carne out with a paper and asked Oller “how he certified and swore so easily what he knew to be contrary to what he had confidentially told the director about to whom was due the great benefit of having first introduced vaccine fluid in this town.” At this point Mexía, “oriented to the reality of the case, remained silent to avoid the altercations that might occur.” Balmis told Oller he was not a man to be trusted, and that he had not sent vaccine to Yabucoa (even though Oller and Mexía gave assurance to the contrary, with details of how it had been done). In Mexía’s opinion, “there was argumentation from side to side; . . . if the director said [something] concerning medicine, doctor Oller would answer; . . . if one shouted, the other would not stay behind in defending his Operation.” The director ended by saying all the people Oller had vaccinated would have to be revaccinated.

Mexía’s deposition is the only one that mentions Balmis’s explanation of his rage: Oller had apparently told the director something which Balmis understood to be contrary to what appeared in the certification to the governor. Mexía is also the only witness to suggest that Oller raised his voice. Colonel Tomás Sedeño, down at the square, heard only Balmis. Standard-bearer Miguel Cabrera ran up the stairs to the landing with a cadet and a second lieutenant from his regiment, and heard Balmis say, “Don Francisco Oller, you don’t know what you’re doing, von still have a lot to study, you walk with closed eyes and the most ignorant man would not have proceeded as you have.” However, as Oller “spoke so low, and apparently with submissiveness,” Cabrera heard none of the doctor’s answers. Laureano de la Vega, the second lieutenant, heard a voice saying, “There is no one in Puerto Rico knowledgeable about vaccine, and you least of all,” but he, too, stated that Oller responded with submissiveness. In contrast, the cook (Juana del Rosario Jiménez) was so busy in the kitchen that she “understood, saw, or heard nothing.”⁵⁰

After several days of epistolary sparring with Balmis, Castro, fed up, wrote to Minister José Antonio Caballero on February 25 to claim that he was being distracted from the task of preparing the defense of the city for the imminent war (“I protest to Your Excellency that this director has vexed me more than anybody”), and to report that Oller did not deserve Balmis’s insults. After all, Balmis had not even seen Oller perform a vaccination, and the latter was offering his children for revaccination, to test the validity of his methods. The governor felt that the director’s insistence on revaccination was spurred more by his wish to see public placards announcing the error than by his desire to promote the welfare of the inhabitants. Furthermore, Castro told Caballero how Balmis had failed, after repeated requests, to revaccinate Arizmendi or anyone else, to test his assertions—after which, if it was shown to be necessary, Castro would have announced the need for a general revaccination.⁵¹

February 25 must have been a difficult day for Castro, as on it he received another letter from Balmis, asking “who will not laugh” at Oller’s (and actually Castro’s) “miserable excuses” to explain the progress of vaccination, “who will not mock the title of epidemic given to smallpox in this city,” and who does not know that to stop smallpox contagion it is necessary to vaccinate all susceptibles? (But then Balmis went on to say that to stop an epidemic in San Juan, with approximately 10,000 residente, one must vaccinate at least half the people.) He insisted on the anecdote about a Sánchez boy vaccinated by Oller in San Juan, who then returned to Yabucoa covered with smallpox; mentioned two revaccinees on whom his vaccine took, said there were many more, and offered to revaccinate all of the 1,557 vaccinated by Oller, if they would come on February 28 and 29.⁵² Castro did not forward this letter, which he considered libelous, to Oller, so as not to further exasperate him; but the governor discussed some of the items verbally with him so that they could be investigated and confirmed or denied. Even Arizmendi was alarmed by Balmis’s tone. The bishop-elect sent Castro a copy of a letter from the director, who offered to revaccinate Arizmendi whenever he wanted, without need of resorting to “intermediarles” (meaning the supreme authority on the island, Castro!). Arizmendi was revaccinated on February 26.⁵³ The next day, in what seems a capitulation to Balmis’s wishes, Castro ordered Oller to notify the 1,557 persons he had vaccinated that they should present themselves to Balmis for revaccination on February 28 and 29. By then, mistrust of Oller’s vaccine was spreading among the public, due to the rumors of its disapproval by members of the expedition, and some parents were spontaneously bringing their children to Balmis’s sessions for revaccination.⁵⁴

The events of February 28 were even more scandalous than the scene of a week before. The governor later described it as the saddest and most bitter day of his life, because he was inhibited from using his power to stop Balmis’s insults, by the realization that detaining the director would obstruct the course of an expedition so dear to the king’s heart. The following description of the scene is in the words of Ramón de Castro (who refers to himself in third person):

The picture sketched by Castro can be completed with the testimony of Oller and other witnesses (except Arizmendi, who considered it an indignity to testify about “that disagreeable scene,” unless he were asked by the king). The events took place in front of a large crowd, amid great noise of people and crying children. At the start of the session, Castro asked Balmis to vaccinate in the parlor adjacent to the room in which the procedure was usually performed, because seats and cushions for the bishops and the governor had been set up in the parlor and the session could proceed there with greater ease. Balmis answered briefly that the place could not be changed, and went into the room to vaccinate, leaving the three personages. After a short while, however, they went into the vaccination room, where there was a sharp debate on whether Dr. Oller’s vaccine was false. Oller had brought 29 of his vaccinees to the session, all revaccinated by Balmis and all without any reaction to the second vaccination. Balmis paid no attention, and when Castro, on Oller’s request, intervened, Balmis said that his task was to vaccinate, not to inspect. Then Castro said that if Balmis did not examine the cases it was clear proof that Oller’s vaccinations had been good. Balmis said that Castro did not understand him, Castro told him to talk to Oller, and Balmis charged that Castro’s intention was to create a quarrel (another observer heard “to provoke a duel”) between the director and Oller, adding that the person Castro had to talk to was Balmis, never Oller, who was an ignoramus in need of much study (a Catalan “who did not even understand Spanish”). Castro told Balmis it was not proper, much less in his presence and that of the bishops, to insult Oller, who had so well served the king with vaccination. Balmis replied that Oller had cheated the king and the people, because he lacked ability, being an ignoramus; when smallpox came back to San Juan and residents began to die because of Oller’s useless vaccinations, Castro would have him hanged. “Unhappy subjects of the king,” the director exclaimed, “if they have received no other favor” from the governor than Oller’s vaccine! Castro then reprimanded Balmis, saying that such disrespectful behavior would be reported to the king, but Balmis answered, “I too speak to the same majesty, and I will do it in person.”

At some point in the discussion, to show Balmis that vaccine had been taken to other towns, letters from the tenientes a guerra were read out loud, but Balmis replied, “Yes sir, of those papers many are made up through diverse and various urgings.” Balmis continually wrung his hands, turning his back at every instant, pacing up and down. Oller later testified that at the end of the vaccination the children were eating, and Balmis went toward them, and with the pretext of expressing his love for them gave out insinuations and satires “surely poured out to offend [Castro].” Other comments may have escaped Oller, he said, because he was “somewhat deaf.” According to Councilman Sánchez Bustamante, the governor and the bishops were chatting with the children and their governess when Balmis said to the children, “Poor little ones, when will we leave Puerto Rico?” To another onlooker, Balmis was so insolent toward Oller that “had he said that to me, we would have both gone over the balcony.”⁵⁶

The director relieved his animosity that same day in a letter to the captain-general of Caracas, announcing the expedition’s departure from San Juan, and suggesting methods to prepare public opinion and the training of practitioners. He hoped thereby to avoid what happened in Puerto Rico, where errors in technique had produced false vaccine, and “where the royal expedition only received the mockery and jeers of the rustic blacks, the only people we found from the harbor to our lodgings.”⁵⁷

In contrast to Castro and Oller, who sent to Spain voluminous letters of complaint, Balmis apparently wrote only two reports to Minister Caballero from San Juan. The first is dated February 27, and relates the expedition’s progress after sailing from Tenerife. The second letter, dated the 29th, deals with the events of the previous day. Balmis describes the same actions as Castro, but the director explains that he started vaccinating before the governor’s arrival, because the bishops were already there, and Castro took so long to come that the public was restless, beginning to leave. Castro, he says further, wanted vaccinations performed in a room with inadequate lighting; and, finally, in warning Balmis to be more respectful when dealing with a captain-general, Castro’s “color changed,” he leaned “on his walking stick, with trembling chin, ready to commit an outrage, which he might have executed had not Providence brought the Most Illustrious Señor Bishop of Michoacán,” who pacified the governor. Balmis could not bring to memory the whole episode, because his “entire machinery was altered by such a treacherous gathering and such rehearsed fraud. ”⁵⁸

On February 29 and March 1, Balmis and Salvany checked Arizmendi’s revaccination incisions, and concluded there was no effect. On the 29th Balmis notified Castro that the expedition would leave on March 2, and praised Mexía for how well he treated them all. From Castro’s account it seems Balmis avoided all occasion to have a final Conference with the governor and the bishop. On the appointed day, Castro went to say farewell to the expedition before seven in the morning, but the director had gone on board ship at five, so Castro gave a farewell speech to the children (who at this stage of the trip must have been beyond amazement) and asked the male nurse in charge of them to transmit the governor’s best wishes to the rest of the staff. Finally, he ordered the municipal councilmen to serve the expedition as long as it was in San Juan—which turned out to be longer than anybody expected. The ship could not sail immediately, for lack of winds.⁵⁹

On March 6, the municipal council, at the captain-general’s request, named Oller and Emigdio Antique to continue vaccinations.⁶⁰ Castro was upset at Balmis’s recommendation of Louis Rayffer (a Frenchman) and Antique (a “young physician who may not even have two years in practice”) to the detriment of the other facultativos who had not attended the royal commissioner’s lectures, but he designated Antique with Oller, so he would not be blamed for not adhering, even in part, to the director’s opinions.⁶¹

Before Balmis’s departure, two announcements further confirmed the correctness of Oller’s procedures. From the town of Yabucoa, Castro received a request from Bernardo Sánchez, practitioner of medicine and surgery, who asked to be allowed to charge wealthy patients four reales (perhaps comparable to four present-day U.S. dollars) per vaccination.⁶² Sánchez’s son (José, “commonly called Porrongo,” age 14) was the boy who Balmis maintained had developed smallpox after vaccination, so father and child were ordered to come to San Juan. They both testified to the vaccination, and the youth, on examination by two surgeons, was found to be free of smallpox scars.⁶³ On March 8, the Havana newspaper La Aurora arrived in San Juan, describing how vaccine had arrived there in the arms of a child vaccinated in Puerto Rico. Doña María Bustamante had her son and two young maids vaccinated in the town of Aguadilla on February 1. She sailed for Havana the next day and arrived on the 10th. A friend took her to Dr. Tomás Romay, who on February 12 vaccinated his 5 children and 37 other persons. Only 9 of those developed vaccine pustules, but the evidence earned María Bustamante the 200-peso prize offered in January of 1803 to whoever would first bring vaccine to Havana. The enthusiasm was so great she was actually awarded 300 pesos. From Havana, the vaccine was taken to Mexico; meanwhile, Oller’s remittance made lymph available at Cumaná in Venezuela.⁶⁴

The ten-day wait for wind on the María Pita must have been very uncomfortable, as life on any ship of those times was bound to be, with the aggravation of keeping nearly two dozen children in close quarters. Besides, the expedition’s staff may have been reluctant to leave the ship even for the most basic of errands. On March 10, Castro received a letter from Balmis, complaining that his group had not been given any meat since March 2. The municipal councilman in charge of supplies (Coronado) answered Castro’s inquiry on the matter stating that there was a general meat scarcity (the towns scheduled to send it that month had not brought any), but that the María Pita had received its meat ration until March 5, and had not requested meat since. The “scandalous” propositions reported by Balmis’s majordomo at the butchers’ (people cursing the expedition, and saying it was a nuisance) were not heard by Councilman Coronado, but may explain why the majordomo stopped asking for meat.⁶⁵

Balmis also took boys from Puerto Rico on board the María Pita. A few days after arrival in San Juan (February 14), Balmis had asked the governor for four boys, aged eight to ten years, to take the vaccine lymph to Caracas. Parents could choose to give up a boy, who would then, with the foundlings, be educated in Mexico, or they could ask for the child to be returned home after the expedition arrived in Venezuela. The boys could be “of whatever caste, because the accident of color has no adverse influence on the vaccine.” Balmis initially accepted four children ceded by the parents to go to Mexico, but then (February 23) decided they would be returned from Venezuela, because the ship was too small. Castro accused Balmis of trickery. The mothers were upset “at being deprived of the promised benefaction,” but agreed (February 24) to let the expedition take the boys to La Guaira for a compensation of 50 pesos. During the long wait for winds, the vaccine pustule matured and dried up on one boy, another developed false vaccine, and a third turned out to have too sickly a constitution. Balmis asked Castro for more children, and this provoked another round of strident recriminations (for example, Balmis: “I am not offended if a governor insults me, when there is a king who honors me”). Whatever boy Castro would send Balmis, the physician found unacceptable. In part the problem arose from the scarcity of unvaccinated young people in town. Also, there was

Balmis was supplied several children by Antonio Peñalver, a drummer in the artillery militia, but they were not suitable either. Castro scolded Balmis for resorting to Peñalver (well known for his “fickleness, inconstancy, and meddling nature”), when the governor and members of the municipal council were already attempting to fulfill the expedition’s needs. Eventually the four necessary boys were found.⁶⁶

Favorable winds finally blew, and on March 12, 1804 the expedition left San Juan for La Guaira. A week later, the ship lost its bearings, and Balmis found himself with lymph on only one child’s arm, the pustule at its peak, and no one susceptible to vaccinate. That day (March 20) the ship found harbor in Puerto Cabello (about 150 kilometers west of La Guaira), where 28 children were injected immediately, thereby assuring lymph transmission. Balmis’s account of this portion of his voyages describes his anxiety at realizing he was about to lose the vaccine, and he blamed the governor of Puerto Rico for creating all kinds of difficulties so that the expedition had left with few children. Nevertheless, the eight-day voyage from San Juan to Puerto Cabello took the same time that Balmis had estimated to sail to La Guaira, and he took from San Juan the number of children he had requested to continue the voyage, so it was clearly unfair to blame Castro for what could have been the end of the expedition.⁶⁷ (In fact, even if the supply of lymph had been extinguished, more could have been obtained from Puerto Rico.)

Balmis’s entrance in Caracas on March 28 was nothing short of triumphal. Then, after performing public vaccinations and instituting a Central Vaccine Board, Balmis carried out the projected division of the expedition. One group, under José Salvany, took the vaccine to present-day Colombia, Ecuador, Peru, and Bolivia. Balmis went on to Cuba, Mexico, the Philippines, Macao, and Canton, and returned to Europe on a Portuguese ship, arriving in Lisbon on August 14, 1806. On Sunday, September 7, 1806 “he was given the honor of kissing the hand” of Charles IV: “His Majesty has shown the greatest interest in hearing about the principal events of the expedition, being extremely gratified with its results, which have exceeded even the hopes which were conceived at its beginning.” Edward Jenner, on receiving the newspaper account of Balmis’s presentation to the king and the accompanying summary of the expedition, called the latter “the most interesting document that has ever reached me on the vaccine subject. ”⁶⁸

While Balmis sailed to Venezuela, Oller and Castro prepared their remonstrances to the court, and in the governor’s report (March 24), a detailed account of expenses is included. Of the total 2,712 pesos outlay, the royal treasury in Puerto Rico spent 951 pesos on the January and February salaries of Balmis and his staif, 133 pesos on the feeding (for 15 days) of the four children sent to La Guaira, and 163 pesos on assorted expenses for all the boys (6 dresses, 4 hats, 25 tunics, 26 pairs of shoes). The accounts submitted by the municipal councilmen (Mexía and Sánchez Bustamante) show vaccine-related expenses (from December 1803 to March 1804) of 1,760 pesos for items such as servants, a cook, kitchen boy, seamstress, a hired slave, bandages, furniture, “36 pounds of cake for vaccinees,” white-wash and ocher for the facade of the house of vaccination (on January 31, obviously in preparation for Balmis’s arrival), salt water to bathe the children, and antojos (whims) for the boys (only 8 pesos). Dinners included wine, and ended with bananas and fruits in syrup for dessert. The children were given arroz con leche, sugar cane, oranges, lemonade, and chocolate. The municipality’s expenses for the 22-day stay of the expedition were 776 pesos, excluding the recompenses (50 to 60 pesos each) offered to the parents who lent their sons for the trip to Venezuela.⁶⁹

The director’s “shameless actions,” as Castro put it, were not left unmentioned. “He omitted no Step and left no stone unturned to further slight me and offend the respect due me. . . . The cabildo itself declares it so, comprehending the venom that they [Balmis’s words] hid.”⁷⁰ These appeals to the crown produced very quick response. When a new governor was appointed that year, the king charged him with investigating the allegations of Castro and Balmis. Toribio Montes was sworn in on November 12, 1804, and he immediately requested reports from Bishop Arizmendi, the city council, and notable citizens of San Juan and other towns. Castro was still in San Juan (and would not leave until 1809). Montes reported that all witnesses concurred that Oller’s vaccine was truly effective, and expressly avoided inquiring about the “fiery disagreements” that had occurred, because his Orders were limited to ascertaining the “legitimacy” of the fluid used in Puerto Rico.⁷¹

Balmis did not leave his instructions for the establishment of a vaccine board in Puerto Rico, although he strived to see such agencies set up in most of the other places he visited. In a letter to the viceroy of Mexico, dated September 5, 1804, he presented his ideas. The board would be under the immediate “protection” of the viceroy and the archbishop of Mexico. It would be formed by seven “distinguished members of [secular and ecclesiastic] society” (among whom the president would be chosen), six physicians, and one representative of the municipal council. Each month, two of the board’s physicians would be in charge of public vaccinations every nine to ten days. To ensure against the propagation of false vaccine, no one would be allowed to vaccinate without the board’s license, and inoculation of natural smallpox would be forbidden. The board would be in charge of dispatching vaccinators to smallpox-stricken towns, for propagation of the fluid, and instruction of the town physicians. Records would be kept of other conditions cured by the vaccine, and of any reports of cowpox in Mexico. Balmis proposed regulating the number of vaccinations according to the number of births, and suggested that a house for public vaccinations be set up, supported by contributions from the archbishop, the municipality, and wealthy persons. He felt that the public would not go to a hospital to get vaccinated because of the general dislike of such places, and the “uncleanliness and weak and sickly constitutions” of the patients there. People should not only get vaccinated, but they should return to the house so that the fluid from their pustules could be used. To this effect, the poor would be offered one peso for the use of vaccine fluid from their arms.⁷²

On August 22, 1804, Governor Castro—who had not yet been relieved —informed the municipal councilmen in San Juan of the royal Order of May 20 of the same year by which, among other things, the king ordered that in every capital a set of rules to maintain the supply and propagation of vaccine fluid be instituted. The order stated that vaccinations should be performed gratis in a ward in royal hospitals, and the number of people vaccinated each time should be in proportion to the number of annual births in the population. The governor scolded the municipality for not having notified him, since March 6, of any further arrangements for promoting vaccinations, so the municipal council asked Antique and Oller to propose the rules for vaccine distribution.

Oller delivered an eight-page plan for the same Services as Balmis proposed in Mexico, but rendered through a completely different structure. Oller and Antique would direct the vaccination effort by performing the operations in San Juan, sending written instructions to physicians and practitioners in the island, and, if necessary, examining their performance. (Here Antique suggested that every vaccinator should come to San Juan to be instructed about the procedure.) All vaccinators would send a monthly report of their activities to Oller or Antique, who would then inform Mexía, the commissioner for the vaccine. The number of vaccinations to be performed in a period would be determined using the census of the city quarters, the parish reports of births, and the lists of vaccinated people, so that a large number of people would be vaccinated initially but eventually 10 to 12 persons would be included in each weekly session. This would benefit the greatest number of people as soon as possible and would ensure continuation of the supply of fluid. The bishop would instruct priests to remember, when baptizing a child, to persuade parents to take the infant for vaccination at 30 days of age, or sooner if there was danger of an epidemic. The municipality would give Commissioner Mexía authority to make tardy citizens get themselves or their children vaccinated. A house, not the hospital (as the king ordered), would be used for vaccinations, because the hospital had no ward available, and, besides, it was at an inconvenient distance from the residential part of town.

The municipal council took action on Oller’s plan without even discussing it. The alcaldes of the four city barrios were ordered to make a list of the citizens in their jurisdiction (especially the newborns) and to submit it within a week. A month later (October 2), Oller and Antique, not knowing even if their report had been considered, complained to Governor Castro that so few people were going to the immunization sessions that there was danger of losing the vaccine. It still took two more months to get the census performed. The alcaldes de barrio excused themselves “because of their limitation in reading and writing,” so the town’s attorney (síndico procurador general) was assigned to help them. He kept giving excuses, and finally delivered the report on November 19. Only then was Bishop Arizmendi asked for a report of the births in the previous five years, which he promptly provided. On December 17, 1804, the municipality approved sending the physicians all the statistics they had requested. By that time, the king signed another law on the use and conservation of vaccine fluid, which, in very general terms, agreed with Oller’s formulations.⁷³

Little information on vaccine Services is available for the period 1805 to 1817. Presumably, Oller and Antique continued vaccinating. The supply of vaccine was extinguished several times, and new lymph had to be brought from the town of San Germán, and even from Santo Domingo.⁷⁴

In April 1818, the boards of health of the towns of Isabela and Manatí (in northern Puerto Rico) reported to Governor Meléndez the presence of smallpox in their towns. (Municipal boards of health were in existence at least since 1809.) Meléndez forwarded the letters to Dr. Oller, who informed the governor that there was smallpox also in San Juan, and that it would probably spread promptly, because many people were ill, many were not vaccinated, others refused vaccination, and many towns had let the vaccine fluid be lost. Oller suggested sending a knowledgeable physician to propagate the fluid throughout the island.

The Superior Board of Health of the island met in San Juan to discuss the Situation. The usual officials (governor, bishop’s deputy, Oller, Antique, and Mexía) instituted the usual measures of epidemic control: the sick were identified and removed to an isolation house, an effort was made to vaccinate the population, and the priests were instructed to persuade their parishioners to get vaccinated. Even so, from April 25 to May 25, 1818 only 154 townspeople were vaccinated. The 42 inmates of the jail and the 500 soldiers of the newly arrived city garrison were also immunized. The board decided that an effort would be made to send vaccine to the rest of the island after the outbreak of smallpox had been controlled in San Juan.⁷⁵

It was evident that the System for propagating the vaccine was not working. The board commissioned one of its newest members, Dr. José María Vargas, to write a proposal to ensure the conservation and propagation of lymph. Instead, Vargas wrote a set of clinical instructions to serve as guide throughout the island. The board approved Vargas’s report, but repeated the request for a plan to organize the vaccine Services. After studying Oller’s plan of 1804 and discussing it personally with Oller and Antique (city physician since 1812), Vargas submitted a proposal which was accepted by the Superior Board of Sanitation on April 28, 1818.⁷⁶

The new proposal created a system almost identical to what Balmis had suggested to the viceroy of Mexico in 1804. (Perhaps Vargas, a Venezuelan, was familiar with the structure of the Caracas Board of Vaccination, created by Balmis.) These new “vaccine regulations” were very detailed as to the procedure for organizing public vaccinations. Oller would be the director and Antique vice-director of immunization Services. Priests’ weekly reports of baptized children would form the basis of lists of candidates for vaccination, and a constable was to notify parents 4 to 6 days in advance of the child’s scheduled date of vaccination. Oller and Antique would supervise the weekly vaccinations, performed by practitioners trained by them and paid ten pesos monthly. (Other physicians could also vaccinate, but had to submit lists of their patients to the vaccine board.) The practitioners would visit subjects 4 days after vaccination to check the results of the procedure and to relieve any discomfort present. Parents were to be told to bring the immunized children to the next vaccination, to serve as the source of fluid. The practitioners were to visit the patients again 10 to 14 days after vaccination. Parents who neglected to bring their children to vaccination were to be forced by the governor or alcalde to attend the next vaccination. A subsidiary vaccination board was to be established in each town and was to submit a monthly report to the insular board. It was made clear that the governor and alcaldes were to support the vaccination boards as another responsibility in “the sacred duty of their office.”⁷⁷

Another means of defense against the spread of infection was the quarantine of infected ships. Just after the smallpox outbreak of April-May 1818 was controlled, a Spanish ship arrived in San Juan on its way to Havana, with a shipment of slaves from Africa. One hundred fifteen slaves had died of smallpox during the voyage, and 20 were still ill. The board of health ordered that the ship should have no communication with land until it went through a double quarantine (80 days) but that all assistance necessary for the continuation of its voyage to Havana would be given.⁷⁸

In March 1819, the vaccine fluid again was exhausted. Oller blamed it on a “rare coincidence,” because in a group of 14 people all the vaccinations were unproductive. No fluid was available anywhere on the island. However, a friend of Dr. Vargas sent the fluid in glass slides from Saint Thomas. That lymph was found to be inactive, so the friend (Dr. Meyer) sent a recently vaccinated woman, and supply was reestablished in San Juan and even sent to Santo Domingo.⁷⁹

The vaccine Services were not changed from 1818 to around 1850. Governors sent orders and circulars to mayors and town physicians reminding them of their duties to keep the population vaccinated and to watch for the development of epidemics.⁸⁰ Dr. Antique died in 1852—the last of the protagonists of the struggles for the introduction of the vaccine in 1803-1804. A smallpox epidemic in 1855-56, soon after his death, showed that the population was still not protected from the disease. For another 20 years, the prevention of smallpox depended on a fragile chain of arm-to-arm vaccination, ship quarantine, patient isolation, and regulations for the handling and burial of smallpox victims. Eventually, the availability of calf vaccine preserved in glycerine (which made arm-to-arm immunization unnecessary and the vaccination of all available susceptibles a possibility), together with the stimulus provided by smallpox epidemics in 1863-66, 1871, 1873, 1875, and 1880-81, paved the way for the establishment of a Provincial Vaccine Institute in Puerto Rico in 1882.⁸¹

The only previous detailed account of the introduction of smallpox vaccine in Puerto Rico, Salvador Brau’s “La viruela en Puerto Rico” (the “description of record” on which all subsequent historians of the expedition have based their understanding of what happened) is incomplete and plagued with errors. A comparison of the documents with Brau’s narration shows that he falsely accuses Balmis of trying to pass off Moreau’s book as his own work, States that Balmis left without giving any public conferences, that the expedition sailed on March 2, and that Balmis decided to go to Venezuela alter boarding the ship. This last Statement is tantamount to a charge of kidnapping, because Brau says the parents were only told that the children were going to Mexico. Later descriptions, quoting Brau, or quoting Balmis’s unreasonable accusations, have presented the altercations surrounding this event as unfortunate incidents unrelated to the expedition’s major work in Mexico and Central and South America. Actually, it was because of the early importation of lymph to Puerto Rico that vaccine use preceded Balmis at almost every stop in the Caribbean. In spite of his experiences in San Juan, furthermore, Balmis did not deal (except in Cuba) in any more productive or amicable fashion with the local physicians and surgeons who had already started to use the Jennerian preventive method.⁸² Therefore, this episode is essential for understanding not only the local context in which vaccination got its Start but the subsequent experiences of the expedition, and its analysis is necessary to rectify previous descriptions of Balmis’s actions.

The Royal Expedition of the Vaccine was a brave and humanitarian undertaking. It is as much a credit to the government that supported it as to the physicians who planned it, the persons who actually traveled in it, and those who helped it on its way. Even if the luster of this enterprise is diminished by the frequency of incidents such as occurred in Puerto Rico, the great success and truly unique achievement of the expedition was its introduction of smallpox vaccine in regions of Spanish America far removed from maritime transportation routes, and also in Asia. In those regions, the efforts of individuals, or even local institutions, could not overcome the obstacles to the survival of a biological product (variola lymph) during long travels, and the population would have had to wait many years while vaccine use slowly diffused geographically.

Castro and Oller were able, proud, and opinionated individuais, who had been victorious in previous military and medical campaigns in Puerto Rico. Castro repelled the British attack of 1797, and Oller obtained the legalization of inoculation in 1792: neither was disposed to defer unreservedly to the wishes of Balmis. (The only official who advised submission to Balmis’s directives—because they came from the king’s special envoy —was a creole, Bishop Arizmendi, whose pastoral duties as peacemaker took priority over other considerations.⁸³) The resulting clash of personalices and Balmis’s refusal (or neglect) to institute a vaccine board in San Juan might be blamed for the slow, inefficient development of vaccine services in Puerto Rico in the early nineteenth century. But it is unlikely that such an agency was the indispensable ingredient for success, given that the regulations of 1818 (very similar to Balmis’s recommendations elsewhere) proved ineffective for assuring a supply of lymph.

The centralized bureaucracy directed by Castro could and did work with speed and efficiency, using fast communications within and outside the island, and obtaining the enthusiastic cooperation of outlying towns, the clergy, and the general public. The extensive knowledge demonstrated in San Juan in 1804 about scientific developments and the medical literature, and its rapid dissemination to the rest of the island, is all the more surprising when one considers that there was no printing press in Puerto Rico at the time. However, the prevention of a smallpox epidemic was seen as an important goal that justified the mobilization of extraordinary governmental and social resources. And in this allocation of priorities, Puerto Rico was in step with the rest of Spanish America. Throughout the king’s American dominions the interest in vaccine spread as no other scientific idea had before.⁸⁴

The public’s enthusiastic initial demand for vaccination in San Juan (where so few children remained unvaccinated that Balmis had trouble finding susceptibles for the trip to Venezuela) is in contrast with later official statements regarding the population’s fear, apathy, or even opposition toward vaccination.⁸⁵ There seems to have been no opposition to vaccination when it was first used in Puerto Rico. The only explanation of later distrust of immunization is contained in a circular sent by the bishop in 1818, ordering parish priests to be present at local vaccinations, so that the public would be encouraged to attend. Priests were to explain to those who believed that vaccine was useless, or that it was even the cause of smallpox, that such results were due only to poor vaccination technique.⁸⁶

Besides the public’s eventual apathy, the main obstacles to the spread of vaccination were the lack of medical practitioners and good roads to inland towns and the intrinsic awkwardness of a method that required keeping a portion of the susceptible population unprotected so that a supply of fluid could be maintained by a chain of vaccination. It was this unvaccinated population, and the group that had been immunized inadequately, or long before, that became infected when a case of smallpox was introduced in the island. Up to the end of the nineteenth century, it was not the formal structure of the vaccine Services, but the interest and insistence of the governors, that determined how many people were vaccinated. As with other nations, Puerto Rico had to wait for new developments in the materials and technique of vaccination, before governmental measures to eliminate smallpox could be truly effective.