Globalisation of Variolation

The Overlooked Origins of Immunity for Smallpox in the 18th Century

Alicia Grant

• Publisher: WSPC (EUROPE)
• Year: 2019
• eBook ISBN: 9781786345868
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Devastating epidemics of untreatable smallpox caused not only deaths but dire disfigurements of face and body as well as one third of all blindness. In the 20th century mortality was estimated at 300 million up to 1978, the year it was proclaimed to be eradicated. Historically, the fact has been overlooked, often forgotten, that the preventative practice of variolation for smallpox was widely adopted internationally during the 18th century and was the precursor to refinement as cowpox vaccination. Never previously traced was the extensive global adoption of the technique or the impetus for this transmission and how, in these countries of its adoption, variolation was the prime mover for a national concept of public health with the establishment of free institutions. The global adoption of the first invasive medical prophylaxis for any disease, the origin of immunity, deserves its place in history.

Contents:

• Acknowledgements
• Foreword
• List of Tables
• List of Figures
• Prologue
• Introduction
• England: The Testing of a Premise (1699-1730)
• Turkey: Religion and Variolation
• England and France: Implementation versus Mentation
• Russia: From Pioneers to Public Health
• Sweden: Theory and Practice
• Colonies of America: Victory for Variolation
• Circassia, Calmucks and China: Sources and Stepping Stones
• Conclusion
• Appendices
• Chronology
• Bibliography
• Index

Readership: Medical doctors and students; historians of science, technology and medicine; universities with a public health faculty; government health institutions.Smallpox;Variolation;Immunity;Public Health00

Introduction

The smallpox was always present, filling the churchyard with corpses … leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover.¹

T.B. Macaulay

The devastating epidemics of smallpox in the 18^th century, recurring on average every four years, caused not only deaths but dire disfigurements. Often dismissed as a mild ‘children’s disease’ up to the middle of the 17^th century, several poems attest to deaths of women during that early period, berating smallpox as ‘Thou that of faces hony-combes dost make’.² It thereafter took a more virulent form and had replaced the plague as the leading infectious cause of deaths in adults in Europe. The affluent as well as the poor were affected causing the death of six reigning monarchs.³

Statistics for smallpox mortality in Europe in the 18^th century were 400,000 each year.⁴ Estimated deaths from smallpox in the 20^th century up to 1978 were 300 million.⁵ WHO (World Health Organisation) gave the worldwide mortality figure for 1967 as two million, yet could formally declare the disease eradicated on 5 May 1980.⁶ The last case of naturally occurring smallpox was Ali Maalin in 1977 in Somalia; the final, unfortunate death was that of Janet Parker in 1978 in Birmingham, due to the virus escaping from the laboratory centre on the floor below her office.⁷ The survivors could suffer from permanent pitted and scarred skin, sealed nostrils, respiratory complications, lame or contracted limbs, mental confusion and also smallpox caused one third of all cases of blindness in England.⁸ Survivors were, however, immune for life — a fact noted following the Athens epidemic in 430 BC by the historian Thucydides, who suffered from the disease himself.⁹

This scenario of suffering was the background to the understandably intense interest evoked by the prospect of a method of avoiding ‘natural’ smallpox, which could have up to 30% mortality with the severe form (variola major virus), by means of the milder form by variolation, which when properly administered had a maximum of 1–2% mortality.¹⁰ This latter figure was possibly not entirely due to variolation but to the fact that natural smallpox had a long incubation period during which there were no symptoms, or none clearly attributable to smallpox; some people went to be variolated but suffered a severe and sometimes fatal attack of the natural smallpox which they had actually contracted earlier.

There has never been an effective treatment for smallpox, although innumerable remedies were tried, the patient either recovered or did not; caused by a virus and not a bacterium even the twentieth century antibiotics could not be of avail. It was both infectious and contagious with no basis for an assumption that the disease could be prompted by fear.¹¹ The most renowned of the Egyptian mummies with the earliest pitted lesions was Ramses V who died in 1157 BC. The first recognisable description of the disease and its course as smallpox was by Bishop Gregory of Tours in 582 AD; twelve years earlier Bishop Marius of Avenches was the first to use the word ‘variola’ — ‘spots’ — later used to refer to the inoculation technique.

In debates concerning the cause of the disease a dominant idea, as expressed in the 18th century by Professor Rosen von Rosenstein in Sweden, was that there was an ungerminated seed in the body, which could be activated by external factors: this originated from the writings of the famous Persian physician Abu Bakr Muhammad Ibn Zakariya al-Razi, known as Rhazes, who first differentiated measles from smallpox in 910 AD.¹² A similar belief was held in China of congenital or foetal poison; in England physicians held either to the theory of miasma, or noxious air, or to the theory of external microscopic agents referred to as animalcules — living agents sucked in with the breath — which was very close to the first viewing of a virus using an electron microscope in 1931.¹³ It had been Richard Bradley (1688?–1732), the first Professor of Botany at Cambridge University, who proposed the living agent theory for infectious diseases of both plants and animals.¹⁴

Variola virus was the active agent causing smallpox in humans and a cutaneous application of variolation was followed by a local lesion, usually with many satellite pustules. Variola major virus caused a more severe attack, and variola minor a lesser; possibly the variola minor strain in earlier centuries was common, when smallpox was referred to as a children’s disease. The tiny smallpox virus was finally seen for the first time in 1947 with use of the electron microscope.¹⁵ Variolation was the first medical invasive prophylactic intervention for a disease, as opposed to quarantine, hygiene and sewage initiatives, and was a great medical contribution of the Enlightenment, leading to the conception and implementation of public health initiatives. It refers only to the prevention of smallpox and it globalised using networking, the latter terms now in vogue, centuries before the present popularity of those words and also relatively fast considering the speed of available modes of transport in the 18^th century.

Variolation has been largely disregarded by historians after the plethora of literature during the 18^th century, during which it saved innumerable lives, the undervalued precursor was overshadowed by the advent of vaccination; the majority of secondary sources in the following three centuries focus on the history of smallpox and show little interest in 75 years of pre-Jennerian variolation, often dismissing variolation in one sentence or one paragraph or totally ignoring it.¹⁶ Cumston’s 380 page medical history mentions only that it was superseded by vaccination; Lichtwardt completely ignores the existence of variolation, writing ‘Smallpox — that pestilence of all ages till the time of Jenner’; Haeser opines that ‘the most praiseworthy discovery in the field of public health was the protection of vaccine for smallpox’; Ackerknecht states ‘one of the greatest contributions … was the general introduction of an effective preventative measure against smallpox toward the end of the century’; Edwardes exclaimes ‘the greatest sanitary fact which the world has ever known’; finally, Fielding Garrison pronounced:

One of the greatest triumphs in the history of medicine … the successful introduction of preventative inoculation by Edward Jenner.

As late as 2013 a medical journal editorial reads ‘prevention of disease was extended to the immunological in the late 18^th century’.¹⁷ Such literature not only denigrates the prior international use of preventative variolation successfully introduced by famous physicians since 1721 but also overlooks the fact that without variolation there would have been no vaccination: Jenner himself, variolated as a schoolboy eight years old, had practised variolation for his patients and in 1789 for his son. He only made a modification to the basic technique in 1796, having thought about it for 18 years, during which more than seven others had initiated vaccination.¹⁸

The scholar Joseph Needham when in Hong Kong declared that variolation was the origin of immunology, a word coined in 1909.¹⁹ Thomas Kuhn in The Structure of Scientific Revolutions presented the concept of a paradigm as a set of theories accepted by members of a given speciality at a given time.²⁰ The term ‘scientific revolution’ was defined as when the paradigm was changed.²¹ Initially forced into the existing paradigm of the 2^nd century Galenic four humours to try to explain its action, variolation was not a revolution until the end of the 19^th century, being the unrecognised seed of a new paradigm which still lay in the future — that of immunology.

In essence variolation was the transference of pustule fluid from a person with smallpox to the skin of a healthy person, commonly done in Europe by dipping a needle or scalpel in the pustule then pricking or scratching the skin of a healthy person; the later practice of vaccination used cowpox pustule fluid in the same way. Some variolators preferred to draw a thread through the pustule then embed a tiny piece of it into an incision in the recipient’s skin — these threads were found to retain the infection for months or years, demonstrating the tenacity of the virus. Samuel Tissot, the experienced variolator from Lausanne, used the same thread for 26 months and James Kirkpatrick in England for 5 years and 11 months; Schulz von Schulzenheim in Sweden recommended keeping the thread for two months before using it in order to get a milder reaction; in Bengal some Brahmin variolation priests used their grandfathers’ inoculum, carried in a cloth.²² Powdered pustule scabs could also be used, indeed there were over thirty methods of transferring either pustule fluid or scabs in many countries: folk practices in rural communities were often ingenious and effective.²³

There were many cognates for variolation: engrafting and ingrafting were terms taken from horticulture: transference was a term later abandoned as it related to a 16^th century belief that diseases could be transferred from people to animals by keeping a sheep or pig in the sickroom; buying the pox was a common folk practice of paying a smallpox sufferer for some scabs to bind on with material to a child’s arm; other terms were infusing and transfusing. Inoculation was a term also used but at the end of the century, when Dr Edward Jenner (1749–1823) modified the method above in 1796 and published his book in 1798 using cowpox pustule fluid, it became cumbersome to have to refer to ‘inoculation by human smallpox’ and ‘inoculation by cowpox’.²⁴ This led to the adoption of the suggestion by Dr Richard Dunning of Plymouth to Jenner in 1803 to use the word he invented to refer to the use of cowpox fluid as ‘vaccination’ (from the Latin vacca for cow), thus differentiating from ‘variolation’ for the previous method (from the Latin vario for spots).²⁵ Here, the term variolation will be used because it refers to prevention solely of the disease of smallpox, whereas the term inoculation has been ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Foreword
• List of Figures
• List of Tables
• Prologue
• Introduction
• Conclusion
• Appendices
• Chronology
• Bibliography
• Index