Variolation was the method of inoculation first used to immunize individuals 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. Only 1–2% of those variolated died from the intentional infection compared to 30% who contracted smallpox naturally. Variolation is no longer used today. It was replaced by the smallpox vaccine, a safer alternative. This in turn led to the development of the many vaccines now available against other diseases.
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 virus was normally spread through the air, infecting first the mouth, nose, or respiratory tract, before spreading throughout the body via the lymphatic system. In contrast, infection of the skin usually led to a milder, localized infection, but, crucially, still induced immunity to the virus. The patient would develop pustules like those caused by 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, India, parts of Africa and the Middle East before it was introduced into England and North America in the 1720s in the face of some opposition. However, inoculation had been reported in Wales since the early 17th century.
Terminology 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 related to but 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 refers to intentionally exposing an individual to a virus, bacterium, other pathogen, or artificial vaccine that may induce active immunity, and inoculation can be done by any suitable route of administration. Many familiar vaccines are injected intramuscularly or swallowed.
The term "inoculation" entered medical English through horticultural usage meaning to graft a bud (or eye) from one plant into another. It is derived from the Latin in + oculus (eye).
Origins China The Chinese practiced the oldest documented use of variolation, dating back to the 16th century, and according to some sources the 11th 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 16th and 17th centuries within China, most notably by Wan Quan.Needham J (1999). "Part 6, Medicine". Science and Civilization in China: Volume 6, Biology and Biological Technology. Cambridge: Cambridge University Press. p. 134. British sinologist Joseph Needham gives a date of the first variolation being dated to between 1567 and 1572. 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. 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.
In the 18th century, two schools of inoculation developed. The Sung-chiang school used scabs from patients of only the mildest cases, while the Hu-chou school did not; the imperial editors of the Yuzuan yizong jinjian tended to favor the latter school. The practice of using scabs from epidemic patients was seen as beneficial by some, but others were convinced of its danger; the Kangxi Emperor approved of it and inoculated both his children and his regular troops. 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.
India India has been suggested as possible origin. There are two accounts from the 18th century of inoculations being performed by itinerant Brahmins: Oliver Coult wrote in 1731 that it had been "first performed by Dununtary a physician of Champanagar" about 150 years before that time (Dhanvantari being the name of the Hindu God of medicine, and a common name among physicians). In 1768, John Zephaniah Holwell wrote of its being practiced for many hundreds of years. Aspects of these accounts have been called into question, but by 1768, inoculation was reportedly being practiced in Bengal. A 1768 letter written by Reverend Mr. Chais (originally in Dutch), described that variolation had been practiced in the Bengal province "for a very long time". The letter describes two methods of variolation: one in which dried scabs from the previous year are rubbed into small pricks made by a needle in the arm, and another in which the dried scabs are mixed with sugar and swallowed by the patient with a sweet and pleasant liquid. The doctors who performed this procedure were known as Tikadars. The term tika is still in use now to mean 'vaccination' in many Indian languages. Holwell ascribes this account to his Brahman informants. However, such a theory has not yet been discovered in any Sanskrit or vernacular treatise. Several historians have suggested that variolation may be older than the 18th century in India.E.g., However, these reports have been disputed. The original ancient text describing this method has not been found. A 2012 paper argued that "since the claim that it was an ancient practice in India has been rejected, there is no reason to assume that it began there"., notes that "However, although there are detailed descriptions of smallpox and its treatment in ancient Indian texts, there is no evidence in these that prophylactic measures were used. ... Since the claim that it was an ancient practice in India has been rejected, there is no reason to assume that it began there." The idea that inoculation originated in India has also been taken into account, although there is little evidence in ancient Sanskrit medical texts clearly describing the practice.Wujastyk, Dominik; (1995) "Medicine in India," in Oriental Medicine: An Illustrated Guide to the Asian Arts of Healing, 19–38, edited by Serindia Publications, London . p. 29. The rumor that vaccination was documented in India before the discoveries of Edward Jenner, widespread since the nineteenth century, can be traced to propaganda tracts written in Sanskrit and the Indian vernaculars by colonial officers, designed to convince pious Indians to accept the newly discovered Jennerian procedure and abandon older variolation practices.
Sudan 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. 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'), a method similar to that used in the Ottoman Empire 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.
Western Europe Variolation in West Europe is first evidenced at the Schola Medica Salernitana in Post-Byzantine or early Norman Italy, where the insertion of infected pustules into the veins of infants is mentioned in the Regimen Sanitatis Salernitanum, which is dated either to before 1050 or to the 12th-13th centuries. The Letters from physicians in Wales published in 1722 indicated the local use of variolation from as early as 1600 near the Welsh port of Haverfordwest. Another reference to variolation is by Thomas Bartholin in 1675.
After coming across the practice in Constantinople, the physician Emmanuel Timoni wrote a letter describing the method in detail, which was later published in the Philosophical Transactions in 1714 and read to the Royal Society. The report caught the attention of a Bostonian minister, Cotton Mather, who mentions an encounter in 1707 with a Garamante from Libya named Onesimus. Mather said that Onesimus's society already had a practice of an operation that would have "given him something of the smallpox and would forever preserve him from it". Benjamin Colman, also a minister, mentions inoculation practices from Africa. In the same period, Lady Mary Montagu, the wife of a British diplomat to the Ottoman Empire, said variolation was widely practiced in the Ottoman Empire.
Lady Montagu
Lady Mary Wortley Montagu had lost her brother to smallpox in 1713. In 1715, she contracted the disease herself. Although she survived, she was left with severe facial scarring. While in the Ottoman Empire she came across the process of variolation as it was introduced and published in Constantinople by two Greek doctors, Emmanuel Timoni and Iacob Pylarino. She first mentioned variolation in the famous letter to her friend, Sarah Chiswell, in April 1717, in which she enthusiastically recounted the process, which in Constantinople was most commonly administered by experienced elderly women. In 1718, she had the procedure 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 variolated in the presence of physicians of the Royal Court in 1721. Both variolations proved successful. Later on that year Maitland conducted an experimental variolation of six prisoners in Newgate Prison in London. In the experiment, six condemned prisoners were variolated and later exposed to smallpox with the promise of freedom if they survived. 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.