Smallpox was a huge illness burden across the world for centuries with frequent epidemics that more than decimated affected populations and left many survivors maimed. The disease appeared in two forms, variola major which was most common and a far more serious infection than variola minor. It was recognized that infection with the minor form provided some protection against the severe form and this led to the practice of variolation, deliberate exposure to the minor form to provide protection against the major form. Variolation was not an exact science and the risk of dying from artificially induced smallpox could be up to one in 50 although this was much better odds than the one in five or six who died from “the natural small pox” [3, p. 243].

From his own observations, Edward Jenner (1749–1823), a general practitioner in Gloucestershire, England hypothesized that cowpox infection, a disease that mostly affected cattle, could also protect against smallpox. Others had made this connection earlier but Jenner is afforded priority because after he had inoculated subjects with matter from a cowpox pustule from an infected cow he deliberately exposed them to smallpox to demonstrate that they were protected [4]. Jenner called this procedure vaccination after the Latin vaccinus meaning of or from the cow.¹ Jenner preferred arm-to-arm inoculation of virus² although it was sometimes necessary to collect vaccine from cows.

In his first publication Jenner included plates to show the differences between smallpox and vaccine pustules and where virus should be collected from a vaccine pustule on an arm [5]. Within a year of Jenner’s first publication on vaccination there were reports that the procedure was not always effective. Jenner quickly realized that practitioners also needed information on when to collect the best virus from pustules and produced a teaching aid in the form of a plate showing pustules from both diseases at four time points [5]. In 1801 Captain C. Gold produced colored drawings of the appearance of the local lesions every couple of days after variolation and vaccination. These drawings were engraved by George Kirtland (1753–1837), the plates were published in 1802 [6, p. 1276].

Luigi Sacco (1769–1836), a physician in Milan, also produced drawings of the development of pustules in Practical Observations on the Use of the Smallpox Vaccine published in 1801 [7]. Sacco wrote a brief for governments on the elimination of smallpox by vaccination and included a section on education of health professionals who would be involved in the program.

To fix the attention of the population, and particularly, of physicians, surgeons and midwives, and to avoid the danger of reaching doubtful or misleading results, it should be prepared in tables with well colored drawings or, even better, two arms made of wax, one with pustules of real vaccine, another with spurious and anomalous pustules. Those pictures should be multiplied and sent to every major town to be regularly examined by professors and midwives. [8, p. 36]

In A Treatise of Vaccination published in 1809 Sacco added more information to the illustrations and introduced the third dimension by showing vaccine pustules at various stages in profile as well as from above (See Fig. 5.1). Pietro Moscati (1739–1824), a respected academic and administrator in Milan commissioned sets of wax models that matched the plates in Sacco’s Treatise. These models showed the structure, color, and evolution of pustules and when and, most importantly, where effective vaccine could be obtained from animals and humans (see Fig. 5.2). The models were sent to Milan, Pavia, Bologna, and Padua, then part of the Cisalpine Republic, and some have survived [5].

Current use of “moulage” is for the process of creating mock injuries on a manikin or simulated-patient but in the nineteenth century a moulage was a realistic model of a body part with a pathological condition made of wax. The term moulage, derived from the French mouler meaning to mould or cast because these copies were taken directly from patients [9] just as some anatomical models made in the seventeenth and eighteenth centuries had been cast from dissections. Before color photography, moulage was a cutting edge educational technology but they were expensive to produce and the size of a collection reflected the wealth and prestige of a hospital or medical school.The process of making a moulage began by taking a plaster cast of the body part (see Fig. 5.3). A wax positive was then made from the plaster mould which was then modified and painted by the mouleur under the direction of a physician [9].