“The Noble Lady sent for me last April, and when I came, she told me she was now resolved to have her daughter inoculated…..having found proper matter I ingrafted it in both arms…Three learned Physicians of the College were admitted, one after another, to visit the young Lady… they saw Miss Wortley playing about the Room, cheerful and well, with the Small Pox rais'd upon her; and that in a few Days after she perfectly recover'd of them.”
This is an account by a Scottish surgeon, Charles Maitland, of the first immunisation ever performed by a doctor in England in the Spring of 1721. In the midst of a smallpox epidemic Lady Mary Wortley Montagu boldly decided to get her three year old daughter “engrafted”. She knew there would be disapproval, as did her surgeon Maitland, but she believed fervently inoculation was the only way to save her child from disfigurement or death from smallpox.
Lady Mary had lived in Constantinople where her husband had been posted as Ambassador. It was here that she was astonished to learn that engrafting of children with poisonous smallpox matter was routine. She had travelled to Turkey in 1716 with her young son and stayed until 1718 during which time her daughter was born. Maitland was with her and she managed to persuade him to investigate the local practice of engrafting with a view to protecting her son.
It was a strange experience for a Scottish medic for he had to seek out one of the elderly Greek ladies who specialised in this treatment, keeping their supplies of infective smallpox matter collected from the pustules of sufferers in walnut shells. When the time came for the engrafting of Lady Mary’s son, Maitland recalled that the Greek inoculator was equipped only with a “ blunt and rusty” needle. He finished the job with his surgeon’s lancet.
Maitland was naturally anxious about the rustic nature of the procedure, but in Constantinople he was far away from the prying eyes of the British medical profession. It was a much more worrying prospect for him to carry out the same engrafting in London. If Lady Mary had had her way she would have kept her daughter’s inoculation secret. But Maitland persuaded her that there should be observers to endorse this new prophylactic.
The crudity of the smallpox inoculation three centuries ago is barely imaginable now. It was unadulterated virus itself which was injected into the arm, and sometimes arms and legs, of the patient. It is not surprising therefore that Lady Mary was vilified rather than congratulated on her brave experiment. However Royalty endorsed it when the King’s daughter Princess Caroline, fearing for the safety of her daughters,, sponsored a trial to test the safety of engrafting the smallpox. London’s notorious Newgate Gaol, where prisoners were manacled awaiting the gallows or transportation, was chosen as a convenient laboratory.
Six Newgate inmates, three men and three women, were chosen as volunteers. If they agreed to be engrafted they would be pardoned and allowed to go free. None was a murderer: they were just petty thieves at a time when stealing anything worth more than £5 worth of goods carried the death penalty. Their chief qualification as volunteers was that they should not have had smallpox.
Charles Maitland carried out the engrafting watched by a gathering of largely hostile physicians and surgeons who doubted the value of such a crude operation. To Maitland’s great satisfaction all the volunteers survived: five had quite severe reactions, one had none as he had lied about not having had smallpox. One of the volunteers was used to prove that the inoculation worked: she was made to lie in a bed with a boy suffering from smallpox. Released from her role as guinea pig she went back to stealing and was transported to the West Indies.
There was one further trial in which orphans in Westminster were the guinea pigs was a success and the inoculation of the Princess Caroline’s daughters went ahead without mishap.
However, take up of inoculation with smallpox was low. Many of the leading doctors opposed it. In a letter to a friend, William Wagstaffe, a physician at Barts Hospital in London wrote in 1722:
“The country from whence we derived this Experiment, will have but very little influence on our faith, if we consider either the Nature of the Climate or the Capacity of the inhabitants, and Posterity perhaps will scarcely be brought to believe that an experiment practiced (sic)
only by a few ignorant women (his italics) amongst an illiterate and unthinking people should, of a sudden, and upon slender experience, so far obtain in of the Politest Nations in the World, as to be received in the Royal Palace”.
Those in the medical profession who practised it by engrafting ridiculously elaborate and more dangerous than it needed to be. After bleeding the patients and starving them the smallpox infection was introduced with a gash rather than a pinprick. For children it could be traumatic. Edward Jenner was inoculated in this old fashioned way when he was about eight years old in 1756-57. As he recalled years later he was bled and fed all kinds of horrible potions so that for the rest of his life he slept fitfully. It has been suggested that this experience influenced his search for a safer form of inoculation later in life, though Jenner never claimed that himself.
It was about the time Jenner was inoculated that a revolution in the way in which the operation was offered and administered was begun in the rural practice of a surgeon in Suffolk. Robert Sutton had been shocked by the severe a reaction his grown up son, aged 24 and fit, had to inoculation. Already in his fifties and new to inoculation, Sutton set out to return the procedure to something closer to the Turkish original, with a minimal incision and less elaborate preparation.
Very soon inoculating became a lucrative business. The surgeon would rent a house especially for inoculating the smallpox and advertise for patients who would pay an all found fee with meat and veg thrown in for the two or three weeks they would be treated. It was important to isolate them as it was known that after inoculation a patient was infectious for two or three weeks. Where a group of patients were inoculated together it did not matter as they were all protected.
Sutton set up a kind of franchise where other surgeons would pay to use his name to indicate they were approved for best practice. He did well but he was soon out gunned by his second son, Daniel, who thought his father’s methods could be improved upon. Daniel cut down the time for inoculation and introduced a crucial innovation: while recovering from the side effects of the procedure his patients were encouraged to stay in the open air as much as possible which helped to reduce their fever.
Daniel Sutton opened his own practice in the Essex village of Ingatestone in 1763 and within a few years had made a fortune. His reputation was founded on his ability to give his patients the mildest attack of smallpox which nevertheless gave immunity. He claimed never to have lost a patient, a claim that was often disputed but never shown to be false. Like his father he franchised his methods all over the country and soon his fame spread abroad. Requests were made for him to save the lives of nobility in Russia and Prussia. But for reasons which have never been explained, Sutton did not travel. Instead his technique was pirated, and others made their fortunes from what became known as the “Suttonian” or the “New method” of inoculation.
English inoculators were regarded as the best in the world having far greater experience than their rivals abroad. Two profited handsomely from Sutton’s reputation and the export of his methods. In 1767 Thomas Dimsdale published a hugely influential pamphlet The current method of inoculating the smallpox which contained only an oblique reference to Sutton though it was put together from a quizzing of his patients.
Dimsdale answered the call to inoculate Catherine the Great of Russia and her son for which he was rewarded with a fabulous income for life and given the title Baron. A Dutch inoculator Jan Ingen-Houz learned the technique in London and was similarly feted in Prussia.
Towards the end of the century there was no reason to believe that
anything might surpass the widely respected and successful Suttonian method of inoculation. There were many mass immunisations in which whole villages and towns were inoculated at once, the fees of the surgeons paid by the parish or wealthy patrons. There was even a proposal by the eminent doctor John Haygarth to create a national inoculating service which would eliminate the disease for ever. In 1796 Daniel Sutton published his only work, The Inoculator; or Suttonian system of inoculation, fully set forth in a plain and familiar manner.
Two years later Edward Jenner, by then established as a country surgeon, published the results of his investigation into the relationship between smallpox and a disease of cattle in his native county of Gloucestershire. Jenner practised Suttonian inoculation extensively. This involved on a number occasions involvement in general inoculations of whole communities. These always threw up a puzzle: some individuals appeared to be immune though they had not had smallpox.
Every inoculator, including Sutton, noticed this. Sutton thought they must have been infected as infants or they had simply forgotten. Jenner, who spent most of his life in his native Gloucestershire, thought he would have known if any of his patients had had smallpox. He recalled in his account of the origin of his investigations that those who had had smallpox were immune to a disease which occasionally infected cattle, known colloquially as “cowpox”. Any farmworkers, male or female, who milked cattle could catch cowpox which was not dangerous but unpleasant enough for them to be off work for a few days. When this happened those who had had smallpox were drafted in.
Jenner was a great observer of nature and believed in a fundamental connection between humans and animals. Over time he considered the idea that cowpox might protect against smallpox. If it did then it could be substituted for smallpox itself. This, in theory, would be a safer form of inoculation. He began to collect case studies in which he would ask those who were immune if they had ever had cowpox. Most of them had, though it had never occurred to them that it might have made them immune.
There is a fairy tale that Jenner got his inspiration from the observation that dairy maids never had their looks spoiled by smallpox. He makes no mention of this, and it would not make sense as cowpox appeared only intermittently. And as many men as women were immune to smallpox.
In the end Jenner took the bold decision to test his theory. He waited for a case in which a woman had caught cowpox while milking. She developed pustules on her hands reminiscent of those caused by smallpox. He chose as his guinea pig a boy called James Phipps whose family he knew. Phipps had not had smallpox. Jenner took some cowpox matter from the infected hand of the woman and, using the Sutton method, used his lancet to introduce the infection. It took and the boy experienced the symptoms of cowpox. A few weeks later he had the boy inoculated with smallpox. It did not take. Eureka!
When he came to write up his findings Jenner thought to give the rustic name cowpox a bit of Latin dignity. He invented the term variole vaccinae to mean literally “smallpox of the cow”. The Royal Society would not accept his paper on what soon became known as
vaccination for lack of convincing evidence. So he published it privately.
Very soon vaccination was greeted as a new wonder drug, a safer form of inoculation. And it turned out it was, in two respects. Firstly as a milder disease there would be fewer fatalities than with inoculation. Secondly, those vaccinated were not infectious. It was a miracle that it worked for there was absolutely no understanding at the time of the nature of viruses or of the human immune system.
Jenner’s discovery did not come out of the blue. By the time he began to promote vaccination, the use of cowpox instead of smallpox, the public was used to the idea of injection with the surgeon’s lancet. He had learned Sutton’s technique of miniscule incisions. All he had to do was swap one infection for another.
There were no inoculations for any of the other infectious diseases that plagued the eighteenth and most of the nineteenth century. Vaccination meant the use of cowpox to protect against smallpox. However in 1881 the French chemist Louis Pasteur who had discovered by chance a way of inoculating poultry against Chicken cholera proposed that all inoculations from then on should be called vaccinations in honour of Jenner.
The heroic early years of inoculation, which were crucial for Jenner’s discovery of vaccination, were erased from medical history. In 2021, while waiting for our Covid Jab we might set the record straight with a cheer for Lady Mary and Daniel Sutton whose rustic talent turned her inspiration into a vital contribution to national health.
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