Inoculation: Smallpox prevention in premodern India

Sitala Mata: the Goddess of Smallpox 

The history of medicine in India has always interested me. Not that I have ever put in any sustained study of the subject, but I do always look up any article that comes to my notice. Someday, when I have more time, I am going to study this more seriously (and travel more widely, write a book on Himalayan wildflowers, take superb bird pictures and grow vegetables among many other things).

However in my studies, such as they are, it is apparent that the History Department of the University of Burdwan appears to be in the forefront of such research. I recently read an article written by the head of the Department, Dr Arabinda Samanta. This paper examined the prevention of smallpox in Bengal in the nineteenth century and it contained some information that really made me sit up.

I was always under the impression that the prevention of smallpox dated from Edward Jenner’s discovery of vaccination. I knew, of course that there were some desultory vaccination procedures which were not very effective in various countries and cultures. However I was unaware that there was a vigorous prevention procedure in India as well.

Smallpox is an ancient disease in India and physicians had, of course, noted that if you once contracted smallpox and recovered, you were immune from the disease for life. This led to the development of the technique of inoculation, which was distinct from vaccination. The procedure involved taking material from a person suffering from smallpox and inserting it into the body of the person who was to be protected. This led to a (hopefully) mild form of the disease, and when the patient recovered, he or she was protected from the disease.  Of course, as one may expect this did not work all the time, and some people died from the effects of the inoculation.

As Samanta points out, “Due to its prevalence during spring, the ailment was also known in Eastern India as the Basanta roga or the spring disease. Basanta Ritu, being a season of festivities facilitating social mobility, helped transmit the disease in all directions. Moreover, the political disintegration of the mighty Mughals facilitating the British acquisition of power, the recurring Maratha raids resulting in displacement of population, the severe drought of 1769 and the consequent famine of 1770 might have favored its dissemination Admittedly therefore, smallpox was a scourge of India, responsible for more victims than all other diseases combined, outstripping even cholera and plague in its tenacity and malignancy.”

Most subaltern groups used to have a fatalistic attitude to the disease. They depended on Sitala Devi the goddess of smallpox to save them from the ravages of the disease. They considered it an affront to the goddess o take any precautions against smallpox and if anybody was afflicted, he was considered a sacrifice to the goddess and it was hoped that this would appease her and save others from the ravages of the disease. 

Many others however availed of the services of the inoculators and according to one survey an astounding 81% of the population had been inoculated by these practitioners. There was a particular group of Brahmins, hailing mainly form upcountry, who came to Bengal from Benaras, Allahabad and Brindaban during the spring, bringing with them the expertise in this operation. They were so skilled that according tone observer, less than one in a million people inoculated developed the full blown disease, making this a fairly safe method of prophylaxis.  The same observer( Holwell) gave  a detailed description of the process: “‘The inhabitants of Bengal, knowing the usual time when the inoculating Brahmins annually return, observe strictly the regimen enjoined, whether they determine to be inoculated or not; this preparation consists only in abstaining for a month from fish, milk, ghee ——. When the Brahmins begin to inoculate, they pass from house to house and operate at the door, refusing to inoculate any who have not, on a strict scrutiny, duly observed the preparatory course enjoined them. They inoculate indifferently on any part, but left to their choice, they prefer the outside of the arm midway between the wrist and elbow, and shoulders for the females. Previous to the operation the operator takes a piece of cloth in his hand and with it gives a dry friction upon the part intended for inoculation, for the space of eight or ten minutes; then, with a small instrument, he wounds by many slight touches, about the size of a silver groat, just making the smallest appearance of blood. Then opening a linen double rag (which he always keeps in a cloth round his waist) he takes from thence a small pledget of cotton charged with the variolous matter, which he moistens with two or three drops of the Ganges water, and applies it to the wound, fixing it on with a slight bandage, and ordering it to remain on for six hours without being moved; then the bandage to be taken off, and the pledget to remain until it falls off itself. The cotton, which he preserves in a double calio rag, is saturated with matter from the inoculated pustules of the preceding  year; for they never inoculate neither with fresh matter, nor with matter from the disease caught in the natural way, however distinct and mild the species. Early in the morning succeeding the operation, four collons of cold water are ordered to be thrown over the patient from the head downwards, and to be repeated every morning and evening until the fever comes on, which usually is about the close of the sixth day from the inoculation; then to desist until the appearance of the eruption (about three days) and then to pursue the cold bathing, as before, through the course of the disease, and until the scabs of the pustules drop off. They are ordered to open all pustules with a sharp pointed thorn as soon as they begin to change their colour, and whilst the matter continues in a fluid state. Confinement to the house is absolutely forbid, and the inoculated are ordered to be exposed to every air that blows; and the utmost indulgence they are allowed, when the fever comes on, is to be laid upon a mat at the door. But in fact the eruption fever is generally so inconsiderable and trifling as very seldom to require this indulgence——. Their regime is ordered to consist of all the refrigerating things the climate and season produce——. These instructions being given, and an injunction laid on the patient to make a thanksgiving poojah or offering to the goddess on their recovery, the operator takes his fees, which from the poor is a pun of cowries, equal to about one penny sterling, and goes on to another door, down one side of the street and up on the other; and is thus employed from morning till night, inoculating sometimes eight or ten in a house”.

This service was not really cheap. According to another observer, the cost of inoculating three children from the middle class was Rs 15 and 4 annas. This included the fees, the cost of the puja and also the presents which included gold which was (presumably) paid to the operator. Of course the cost varied according to the paying capacity of the patient ( nothing really changes in medical practice).  In later years this lucrative service was taken over by less skilled operators leading at times to large mortality figures in the inoculated population. There are records that “in the villages of Sonatikoree in Hooghly district nearly 1,000 boys and girls were inoculated some time before 1850 of whom 300 died. Again in the village of Caderpore among 100 children that were inoculated, more than 20 cases had terminated fatally”

After the 1850s, the practice decreased as vaccination took over and though some sections of the population stood out against the practice, modern medical practices won out in the end.

One interesting sidelight; my mother tells me that as late as the nineteen forties, whenever vaccinators  entered the villages of East Bengal , ( my mother’s parental house was originally in Jessore District, now in Bangladesh), many men and women used to rush to hide in the jungles neighbouring the village until the health workers had safely departed. I still remember being vaccinated every year against smallpox and typhoid. The injection for the latter was painful and left the arm swollen and often caused fever. Fortunately, safer hygienic measures and better vaccines have made these compulsory vaccinations out of date and my daughter was born in a fortunate time when smallpox was a memory and typhoid vaccinations were unnecessary.

(This post is based on the article Arabinda Samanta: Smallpox in nineteenth century Bengal.  Indian Journal of History of Science, 47.2 (2012) 211-240)