Variolation

Variolation or inoculation was the method first used to immunize an individual against smallpox (Variola) with material taken from a patient or a recently variolated individual in the hope that a mild, but protective infection would result. The procedure was most commonly carried out by inserting/rubbing powdered smallpox scabs or fluid from pustules into superficial scratches made in the skin. The patient would develop pustules identical to those caused by naturally occurring smallpox, usually producing a less severe disease than naturally acquired smallpox. Eventually, after about two to four weeks, these symptoms would subside, indicating successful recovery and immunity. The method was first used in China and the Middle East before it was introduced into England and North America in the 1720s in the face of some opposition. The method is no longer used today. It was replaced by smallpox vaccine, a safer alternative. This in turn led to the development of the many vaccines now available against other diseases. Systematic inoculation throughout the country, isolation of patients, decontamination of potentially contaminated fomites, supervised inspectors responsible for specific districts, rewards for observation of rules for isolation by poor persons, fines for transgression of those rules, inspection of vessels at ports, and prayers every Sunday. Variolation or inoculation was the method first used to immunize an individual against smallpox (Variola) with material taken from a patient or a recently variolated individual in the hope that a mild, but protective infection would result. The procedure was most commonly carried out by inserting/rubbing powdered smallpox scabs or fluid from pustules into superficial scratches made in the skin. The patient would develop pustules identical to those caused by naturally occurring smallpox, usually producing a less severe disease than naturally acquired smallpox. Eventually, after about two to four weeks, these symptoms would subside, indicating successful recovery and immunity. The method was first used in China and the Middle East before it was introduced into England and North America in the 1720s in the face of some opposition. The method is no longer used today. It was replaced by smallpox vaccine, a safer alternative. This in turn led to the development of the many vaccines now available against other diseases. The terminology used to describe the prevention of smallpox can cause confusion. In 18th-century medical terminology, inoculation refers to smallpox inoculation. Confusion is caused by writers who interchange variolation and vaccination through either mistranslation or misinterpretation. The term variolation refers solely to inoculation with smallpox virus and is not interchangeable with vaccination. The latter term was first used in 1800 soon after Edward Jenner introduced smallpox vaccine derived from cowpox, an animal disease distinct from smallpox. The term variolation was then used from the 19th century to avoid confusion with vaccination. Most modern writers tend to refer to smallpox inoculation as variolation throughout without regard for chronology, as is used here. Further confusion was caused when, in 1891, Louis Pasteur honoured Jenner by widening the terms vaccine/vaccination to refer to the artificial induction of immunity against any infectious disease. Inoculation is used synonymously with injection in connection with the use of vaccines or other biopharmaceuticals, but has other meanings in e.g. laboratory work. The Chinese practiced the oldest documented use of variolation, dating back to the fifteenth century. They implemented a method of 'nasal insufflation' administered by blowing powdered smallpox material, usually scabs, up the nostrils. Various insufflation techniques have been recorded throughout the sixteenth and seventeenth centuries within China.:60 According to such documentation, mild smallpox cases were selected as donors in order to prevent serious attack. The technique used scabs that had been left to dry out for some time. Fresh scabs were more likely to lead to a full-blown infection. Three or four scabs were ground into powder or mixed with a grain of musk and bound in cotton. Infected material was then packed into a pipe and puffed up the patient's nostril. The practice of variolation is believed to have been ritualized by the Chinese. The blowpipe used during the procedure was made of silver. The right nostril was used for boys and the left for girls.:45 Variolated cases were treated as if they were as infectious as those who had acquired the disease naturally. These patients were subsequently kept apart from others until the rash had cleared. Two reports on the Chinese practice were received by the Royal Society in London in 1700; one by Dr. Martin Lister who received a report by an employee of the East India Company stationed in China, and another by the physician Clopton Havers. But no action was taken. Similar methods were seen through the Middle East and Africa. Two similar methods were described in Sudan during the late eighteenth and early nineteenth centuries. Both had been long established and stemmed from Arabic practices. Tishteree el Jidderi ('buying the smallpox') was a practice seen within the women of Sennar in Central Sudan.:61 A mother of an unprotected child would visit the house of a newly infected child and tie a cotton cloth around the ailing child's arm. She would then haggle with the child's mother over the cost of each pustule. When a bargain was struck, the woman would return home and tie the cloth around her own child's arm. Variations of this practice included bringing gifts to the donor. The second method was known as Dak el Jedri ('hitting the smallpox'),:61 a method similar to that used in Turkey and eventually transported into England. Fluid was collected from a smallpox pustule and rubbed into a cut made into the patient's skin. This practice spread more widely through Africa. It may have also traveled with merchants and pilgrims along the middle-eastern caravan routes into Turkey and Greece.:15 Although variolation had become common practice in China and much of Africa by the seventeenth century, Western European medicine still saw the practice as being nothing more than folklore. It would not be until Italian physician Dr. Emmanuel Timoni of Constantinople promoted the practice that variolation began its spread through Western Europe. After coming across the practice in Constantinople, Timoni wrote a letter describing the method in detail which was later published in the Philosophical Transactions in early 1714.:77 His account would become the first medical account of variolation to appear in Europe. Although the article did not gain widespread notoriety, it caught the attention of two important figures in the variolation movement, Bostonian preacher Cotton Mather and the wife of the British Ambassador to the Ottoman Empire, Lady Mary Wortley Montagu. No stranger to smallpox, Lady Mary had lost her brother to the devastating disease. Soon afterwards she also contracted smallpox. Although she survived she was left with severe facial scarring. While in Turkey she came across the process of variolation as it was practiced amongst the people of Constantinople. She first mentioned variolation in the famous letter to her friend, Sarah Chiswell, in April 1717.:55 in which she enthusiastically recounted the process, which in Constantinople was most commonly administered by experienced elderly women. In 1718, she had the practice conducted on her five-year-old son, Edward Montagu. The procedure was supervised by the embassy doctor Charles Maitland. On her return to England she had her four-year-old daughter inoculated in the presence of physicians of the royal court in 1721.:90 Both variolations proved successful. Later on that year Maitland conducted an experimental inoculation of six prisoners within the Newgate Prison of London. In the experiment, six condemned prisoners were variolated and later exposed to smallpox with the promise of freedom if they survived.:45 The experiment was a success and soon variolation was drawing attention from the royal family who helped promote the procedure throughout England. However, variolation caused the death of Prince Octavius of Great Britain, eighth son and thirteenth child of King George III in 1783. Despite opposition, variolation established itself as a mainstream medical treatment across England. Part of its success was founded on statistical observation which confirmed that variolation was a safer alternative to contracting smallpox naturally, strengthened by the assumption that it protected against the disease for life. The major faults of variolation lay within its simplicity. Doctors sought to monopolize the simple treatment by convincing the public that the procedure could only be done by a trained professional. The procedure was now preceded by a severe bloodletting, in which the patient was bled often to faintness in order to 'purify' the blood and prevent fever. Doctors also began to favor deep incisions, which also discouraged amateurs.:18 Thomas Nettleton (1683–1748) was a precursor of the Suttons around 1722. The main forerunners of the English variolation movement were the Suttons, a family of physicians who would revolutionize the practice of variolation. The patriarch Robert Sutton was a surgeon from Suffolk who began experimenting with the practice of variolation. In 1757 the procedure failed on one of his sons.:20 He sought a new method in which the procedure would become as mild as possible. By 1762 he began advertising 'A New Method of Inoculating for Small-Pox.' Sutton kept his method a secret and only passed it down to his three sons. The mystique and effectiveness behind this new method helped to promote their business which soon became wildly successful. They established a network of variolation houses and clinics and offered franchises to other variolators for a share of the profits and on the condition that the secret would not be revealed. By 1770, the Suttons had treated over 300,000 satisfied customers.:94 Daniel, the eldest of the Sutton sons, eventually revealed the family secret in his book The Inoculator published in 1796.:22 The success of their method lay in a shallow scratch, careful selection of only mildly affected donors, and no bleeding or extreme purging. Although the renown of the Suttons gradually faded after this revelation, the family's lasting impression would remain for generations.