Variolation and the Prehistory of Vaccination Quiz

Answer: Variola

Smallpox, the deadly disease that once wiped out entire villages and left survivors pocked and scarred, is caused by the variola virus, and if you're wondering, yes, this is where we get the term "variolation". Not the most considerate houseguest, variola spread through respiratory droplets and sometimes contaminated objects, turning everyday interactions into potential death sentences.

The last natural case of smallpox in the United States occurred in 1949, and the last naturally transmitted case worldwide was recorded in Somalia in 1977. In 1980, after a concerted global vaccination campaign led by the World Health Organization, humanity finally declared smallpox eradicated. It remains the only human disease to receive that honor. Polio, measles, and the common cold are still out there living their best lives.

Today, smallpox exists only in two secure laboratories (in the U.S. and Russia) under tight security, one hopes. If a single confirmed case were to appear in the modern world, it would be treated as an international health emergency, because nothing ruins your day quite like the sudden return of an eradicated plague.

Answer: China

The earliest documented practice of variolation comes from 16th-century China, although some historical claims point to India as a possible earlier origin. Unfortunately, India never got it writing, so the honor goes to China.

Okay, here's where things might get a little gross.

Chinese practitioners developed a comparatively refined version of variolation: they "harvested" scabs from patients recovering from mild smallpox cases (trial and error taught them that fresh scabs led to worse outcomes), dried these thoroughly, often in sunlight, and ground them into a powder. This powder was then... um, blown up a patient's nostril with the hope that it would cause a mild infection and, more importantly, lasting immunity.

Though the practice later spread to the Middle East, Africa, and Europe (using different techniques, including skin incisions and infected pus), it always came with some risk. Roughly 1-2% of those inoculated died from the procedure.

Such is the grim math of epidemics. A full-blown case of smallpox has a 30% mortality rate, and in affected regions, the risk was worth it.

Answer: Buying the Smallpox

"Tishteree el Jidderi" roughly translates to "buying the smallpox," a phrase that sounds like a terrible idea unless you understand the context. This term referred to a traditional practice in some parts of the Middle East and northern Africa (particularly Sudan and Egypt) where mothers would deliberately expose their children to smallpox under controlled circumstances to induce immunity.

The "buying" part of the phrase reflects the ritual and transactional nature of the act. It sometimes involved giving gifts or small payments to a woman who had access to material from someone recovering from a mild case of smallpox. The idea was to purchase not the disease, per se, but the protection that came with a survivable case. Naturally, there was no guarantee the case would remain mild but, again, we run up against the math of surviving an epidemic.

Though documentation of these practices is spotty, oral histories and colonial records give us glimpses into how widely such techniques were employed across cultures long before the West formalized inoculation.

Answer: A Slave

In 1706, the Puritan minister Cotton Mather came to own a human being named Onesimus, enslaved and brought to Boston from West Africa. Mather, curious about a scar on Onesimus's arm, asked him about it. Onesimus explained that he had undergone a procedure in his homeland to guard against smallpox. As Mather later recorded, Onesimus said, "People take Juice of Small-Pox; and Cut the Skin, and put in a drop."

Mather, recognizing the medical potential, began advocating for the procedure during Boston's smallpox epidemic in 1721, causing a strong backlash. Variolation was viewed with suspicion, especially coming from an African slave. The local newspaper mocked him, and someone even threw a bomb through his window (it didn't actually detonate, but I think it still qualifies as a hostile response).

Despite opposition, Mather's support for variolation helped establish its legitimacy in the American colonies.

Answer: The Princess of Wales

The woman who helped make variolation all the rage in Europe was Caroline of Ansbach, the Princess of Wales. Influenced by the advocacy of Lady Mary Wortley Montagu, who had witnessed the practice firsthand in the Ottoman Empire, Caroline became curious about the procedure's potential to protect against smallpox.

Of course, she didn't have her children inoculated with a procedure based on word of mouth alone. She wasn't a horrid mother. Nope. Caroline got King George I to variolate a group of prisoners and orphans to see what happened.

Satisfied that the procedure wouldn't immediately dispatch her little heirs to the next life, Caroline had her own daughters inoculated in 1722. This royal endorsement was the tipping point that transformed variolation from exotic curiosity into elite medical trend, eventually trickling down to commoners who hoped to avoid the more traditional method of dying from smallpox.

Answer: Losing a son to variolation

Robert Sutton, an English surgeon from Suffolk, suffered a devastating personal loss when one of his children died from variolation, a grim reminder that early inoculation was no guarantee of safety. However, rather than retreat from the field, Sutton and his family used the loss as a catalyst to transform the procedure into something far more effective and far less deadly.

What came to be known as the Suttonian method emphasized a gentler approach: a tiny intradermal scratch in the skin instead of a deeper incision, less smallpox material to provoke immunity, and careful patient management before and after the procedure.

The method worked. The Sutton family began to run what one can describe as a variolation dynasty, eventually treating an estimated 300,000 patients with an impressively low complication rate. Their success helped normalize variolation among the public and medical community alike.

Answer: Collecting infected pus from recently deceased patients

Johnnie Notions may sound like a Dickensian apothecary or an 18th-century superhero with a lab coat for a cape, but he was in fact a Shetland textile worker-turned-health innovator. With no formal medical training, Notions used keen observation and local materials to create a variolation method that was remarkably effective. If records are to be believed, he boasted zero fatalities among his hundreds of patients.

He did not collect pus from deceased smallpox victims. Instead, he harvested material from live patients, then aged it carefully. His method included drying the infected pus using peat smoke, sealing it between glass sheets, and burying it underground for several years to weaken its potency. When ready, he would apply it via a shallow intradermal cut, delivering just enough virus to provoke immunity without full-blown illness.

Answer: Russia

In 1768, amidst growing concerns over deadly smallpox outbreaks, Catherine the Great personally underwent variolation herself after securing one of the best doctors in Europe and having him smuggled in for the job.

That doctor was Thomas Dimsdale, a British physician and variolation specialist. He arrived in Russia with enough medical gear to outfit a small clinic and, after some covert trial runs (on servants, naturally), he variolated Catherine and her son, Grand Duke Paul. The results were a success: Catherine suffered only mild symptoms and gained immunity.

After her recovery, she ordered a nationwide campaign to promote variolation. Tens of thousands of Russians followed her example, helping to reduce smallpox deaths and paving the way for later vaccination efforts.

Answer: Soldiers

In February 1777, amid a deadly smallpox epidemic, George Washington made a radical decision: he ordered that every soldier in the Continental Army be variolated. This was no small feat. Variolation wasn't without risk, and deliberately infecting an army in the middle of a war sounds like the beginning of a very bad plan.

However, smallpox was spreading faster than the British could fire muskets, and it was crippling the American forces. Some units saw infection rates as high as 50%. Washington's directive is now considered the first mass immunization policy in U.S. history. The inoculations were carried out by military surgeons and civilian physicians, often in secret, to avoid tipping off the British that troops were temporarily vulnerable.

Estimates suggest that tens of thousands of soldiers were inoculated over the course of the war. While variolation caused illness and some deaths, strategically it was vastly preferable to uncontrolled outbreaks. Washington's actions are credited with preserving troop strength and may have literally changed the course of the American Revolution.

Answer: Edward Jenner

It's part medical milestone and part ethical minefield, at least by modern standards. In 1796, English physician Edward Jenner intentionally infected James Phipps, an 8-year-old boy, with material taken from a cowpox sore on a milkmaid named Sarah Nelmes. Cowpox was known to cause a relatively mild illness in humans, but rumors and folklore suggested it could protect against smallpox. Jenner was determined to put that theory to the test. Young James would be the test subject.

Once the boy developed a mild illness from exposure to cowpox and recovered, Jenner exposed him to actual smallpox. Phipps didn't get sick, and Jenner concluded that the cowpox infection had indeed conferred immunity. It was the first scientifically documented vaccination, a term derived from "vacca", the Latin word for cow.

The method spread quickly. Napoleon Bonaparte endorsed it (after vaccinating his army), as did Thomas Jefferson, who had it practiced at Monticello. Jenner's technique eventually replaced variolation, especially after governments began to outlaw the older, riskier method. And while Jenner's methods wouldn't survive a modern ethics board, his legacy is solid: he gave us the first vaccine, and a cool new word with it.