Or not, as the case may be.
Smallpox is the greatest success story in the history of medicine. It once took huge numbers of lives — as many as half a billion people in the 20th century alone — and blinded and disfigured many more.
So writes the distinguished historian of science, Steven Shapin in the LRB (A Pox on the Poor, February 4, 2021). He is reviewing The Great Inoculator: The Untold Story of Daniel Sutton and His Medical Revolution).
In historical times you had a one in three chance of getting smallpox, and, if you got it, the case-fatality was 20%. Some outbreaks, however, had a case-fatality of 50% and, unlike Covid-19, its preferred targets were children.
My exposure to smallpox was (thankfully) limited. My mother told me that there was an outbreak in South Wales and the West of England when I was around five or six. There was widespread vaccination, but kids like me with bad eczema, were spared, with the parent advised to ‘shield’ the child indoors (my sympathies go to my mother). (The risk was from the grandly named, but sometimes fatal, Kaposi’s varicelliform reaction, which was due to the vaccinia virus — not smallpox — running riot on the diseased skin).
As a med student, I remember learning how to distinguish the cutaneous lesions of smallpox from chicken pox. Smallpox was declared eradicated in 1980, but, as a dermatology registrar, seeing the occasional adult with chickenpox who seemed so ill (in comparison with kids), I often had doubts that I had to reason away. Perhaps those stores held by the US and USSR were not so secure…
Jenner and smallpox vaccination go together in popular accounts, but the history of this particular clinical discovery is much older and richer — at least to me.
As ever, in medicine, and in particular for anything involving the skin, the terminology is confusing. The Latin name for cowpox is Variolae vaccinae, meaning the pox from the cow (vacca). It was Pasteur who subsequently honoured Jenner by deciding that all forms of inoculation be called vaccination.
Edward Jenner took advantage of the already-known fact that whilst milkmaids tended to be afflicted with the far more mild cowpox virus, they rarely suffered from the more serious, smallpox (they are different, but related, viruses). Jenner, in 1796, inoculated an eight-year-old boy with the pus from a milkmaid’s cowpox sore. After being exposed to smallpox material the boy appeared immune, in that he did not suffer adversely when subsequently exposed to smallpox.
Once Jenner’s method was accepted as safe, Acts of Parliament introduced free vaccination n 1840, and vaccination became obligatory in 1853.
I had never been quite certain of the distinction between inoculation and vaccination, but there is history here too. Shapin writes that the term inoculation was borrowed from horticulture — the grafting of a bud (or ‘eye’) to propagate a plant (something I was taught how to do in horticulture lessons when I was aged 11, in school in Cardiff, by Brother Luke, who, I thought so old, he might have been a contemporary of Jenner). Why the name is apt is explained below.
Before vaccination, inoculation was actually meant to give you a direct form of smallpox (this was also referred to as variolation, after variola, the term for smallpox). The source material, again, was from a lesion of somebody with smallpox. The recipient it was hoped would develop a milder version of smallpox. Shapin writes:
The contract with the inoculator was to accept a milder form of the disease, and a lower chance of death, in exchange for a future secured from the naturally occurring disease, which carried a high chance of killing or disfiguring.
Shapin tells us that Lady Mary Wortley Montagu, when holed up with her husband in Constantinople in 1717, heard stories about how such ‘in-grafting’ was in widespread use by the ‘locals’. She was scarred from smallpox, and therefor she had the procedure carried out on her then five-year-old son. The needle was blunt and rusty, but her son suffering just a few spots and the procedure was judged a success. He was now immune to smallpox.
Not surprisingly, the story goes back further: inoculation was folk medicine practice in Pembrokeshire as early as 1600, and the Chinese had been blowing dried, ground-up smallpox material up the nose for many centuries.
There is capitalism and then there is capitalism.
The London medical establishment were apparently not too impressed with the non-British origin of such scientific advance, nor its apparent simplicity (and hence low cost). So, they made the procedure made much more complicated, with specific diets being required, along with advice on behaviour, and, of course, blood-lettings and laxatives, all in addition to not just a ‘prick’ but a bigger incision (payment by the inch). The physician’s ‘fees’ no doubt rose in parallel. Not a bad business model, until…
There is plenty of room at the bottom.
The London physicians’ ‘add-ons’ put the treatment costs of inoculation out of reach of most of the population, restricting it, for decades, to the ‘medical carriage trade’. Along comes Richard Sutton, a provincial barber-surgeon, with no Latin or Greek, no doubt, who effectively industrialised the whole process, making it both more profitable and cheaper for the customer.
Based in a village near Chelmsford, he inoculated tens of thousands locally. The method was named after him, the Suttonian Method. On one day he inoculated 700 persons. Incisions (favoured by the physicians) were replaced by the simpler prick, and patients were not confined, but instead told to go out in the fresh air (day-case, anybody?). Product differentiation was of course possible:spa-like pampering in local accommodation was available for the top end of the market, with a set of sliding fees depending on the degree of luxury.
Splitting the market and niche pricing were aspects of Sutton’s business success, but so too was control of supply. The extended Sutton clan could satisfy a significant chunk of provincial demand, but Daniel also worked out a franchising system, which ‘authorised’ more than fifty partners throughout Britain and abroad to advertise their use of the ‘Suttonian System’ — provided they paid fees for Sutton-compounded purgatives, kicked back a slice of their take, and kept the trade secrets. Control was especially important, since practically, anyone could, and did, set up as an inoculator. The Suttons themselves had become surgeons through apprenticeship, but apothecaries, clergymen, artisans and farmers were inoculating, and sometimes parents inoculated their own children. The profits of the provincial press were considerably boosted as practitioners advertised their skills at inoculation and their keen prices. Daniel went after competitors — including his own father-in-law and a younger brother — with vigour, putting it about that the Suttonian Method depended on a set of closely held secrets, to which only he and his approved partners had access. His competitors sought to winkle out these secrets, occasionally pouncing on Sutton’s patients to quiz them about their experiences.
Sutton admitted that had ‘lost’ five out of forty thousand patients (due to smallpox). He offered a prize of 100 guineas to anybody who could prove he ever lost a patient due to inoculation, or that any patient got smallpox a second time. More confident, and perhaps more generous, than modern Pharma, I think. By 1764, Sutton had an annual income of 6300 guineas — over one million sterling in today’s money.