The Rest of the World: Variolation to Vaccination

Imagine living in an era where diseases reigned supreme. You think we have it bad now because of COVID-19, but with modern medicine, the effects are not nearly as severe as they could be. During times without the healthcare we take for granted, one of the most brutal diseases of all time was smallpox. Do not be fooled by the name, because this abominable disease played neither a small, nor insignificant part in the history of the human race.

Smallpox is a disease caused by the variola virus, which evolved from an African rodent. The disease was acutely contagious; patients developed fever and distinctive, progressive skin rash. The symptoms were so severe they caused systemic shock (body wide infection) and toxaemia (toxins in the blood). As a result, smallpox had a fatality rate of sixty percent for adults and eighty percent for children. 

The existence of smallpox dates back centuries; the earliest evidence of smallpox was found in the mummy of Pharaoh Ramses V, who is suspected to have died from smallpox in 1142 BC. It is believed that smallpox emerged even earlie and that the disease caused many disastrous outbreaks throughout the centuries. Yet the first form of defence against it was not developed until the 15^th century, more than two millennia after its confirmed appearance. 

Variolation, named after the variola virus, was the first method of inoculation, which means artificially inducing immunity to a pathogen by introducing it to the body’s immune system. It was a major stepping stone for modern medicine. 

While there is a lot of controversy on the origin of variolation, the two major theories are as follows. Variolation was invented in 15^th century China and spread to India, parts of Africa and the Middle East. The Chinese method consisted of blowing scabs from an infected individual into another’s nostril though a pipe and was believed to be ritualised. Another possible origin is India: it is speculated that variolation had been practiced for centuries before the Chinese, since it was described in ancient Sanskrit texts. The Indian method was slightly different; the virus was introduced via a small cut in the skin instead of in the nostrils. However there is opposition to this theory. There is no solid evidence proving which source is the actual origin, so results remain inconclusive.

Variolation was first described to the Royal Society of London in 1700 by the physician Clopton Havers and the East India Company employee Dr Martin Lister, who was stationed in China. Then in 1714, two Greek doctors residing in Constantinople, Emmanuel Timonius and Iacob Pylarinos, published an article about variolation in a Royal Society magazine. No action was taken to investigate their claims, despite the potential of the prevention of smallpox and an outbreak in 1713. 

Lady Mary Wortley Montagu was the one to introduce variolation in Britain. She came across the procedure in Constantinople in 1717 as she was the wife of the British Ambassador to the Ottoman Empire, and mentioned it in a letter to her friend, Sarah Chiswell. She successfully variolated her five-year-old son in 1718 and her four-year-old daughter in 1721. This brought variolation to the attention of the royal family and led to its rise in popularity. Variolation was eventually established as a mainstream medical procedure. 

Variolation also quickly spread to America. Its earliest use was in 1706 Boston. Boston had previously suffered smallpox outbreaks in 1690 and 1702. Onesimus, slave to the minister Cotton Mather, admitted to having been variolated as a child in Africa, prior to his enslavement. Onesimus’ description of variolation, in conjunction with texts from the Royal Society that Mather had read, led to his advocation of variolation. This resulted in the distribution of variolation during an especially severe smallpox outbreak in 1721-22. However, his methods faced scrutiny from many, and some outright believed that Onesimus planned to poison the city. Despite those difficulties, variolation was tremendously successful during the 1721-22 smallpox outbreak, reducing the fatality rate from one in six, to one in fifty. Onesimus’ contribution, although massively important to the spread of variolation and later development of vaccines, was not recognised. The only award he received was in 2016, three hundred years after his death, when he was given the fifty second place as one of the one hundred best Bostonians of all time by  Boston magazine.

Having said that, variolation did come with risks. Variolated individuals could still die from the disease, even though chances were much reduced compared to those who contacted the disease naturally. In addition, they could spread the virus to uninfected people, albeit a weaker version. It was those risks that caused doctors and scientists to find a safer alternative to variolation. That is where Edward Jenner came in. In the 1760s, it was discovered that cowpox, a disease contracted by milkmaids and those regularly exposed to cows, protected people from smallpox. Jenner used the aforementioned information to develop the first ever vaccine in 1796, which enormously contributed to the later eradication of smallpox. 

The key difference between vaccination and variolation is the sample of the virus used. For variolation, a weakened but still active sample of the pathogen is rubbed into a small cut in the skin. Meanwhile, vaccination entails injecting an inactive sample directly under the skin. This makes vaccination much safer.

As vaccination rose in popularity, the use of variolation started to decline since vaccination was deemed a much safer practice. Eventually, variolation was illegalised. Today, variolation is almost never mentioned while Jenner is remembered as the father of vaccination. Nevertheless, that does not mean variolation and its pioneers should be forgotten, when their contributions potentially saved thousands of lives and inspired the development of vaccination. 

Charikleia Kokkini is a Year 10 student at Friern Barnet School, London. She particularly enjoys physics and spent her winter half-term researching and writing this article for I, Science. We wish her the best of luck in her future scientific and writing endeavours!