Cure or Protection? The meaning of smallpox inoculation,ca 1750–1775

The idea that smallpox could be eradicated was not necessarily the ultimate aim when inoculation was introduced in Europe in the 1720s. This potentiality was not clearly articulated as an aim until the end of the eighteenth century. This article argues that during most of the eighteenth century, the main aim of inoculation was to lead people as safely as possible through what was regarded as an unavoidable disease. Inoculation became safer, simpler and less expensive from the 1760s, but the changing ideas about its potentiality had more complex roots. A new understanding was produced through an interaction between inoculation practice, more general medical theory and developments within probabilistic thinking and political arithmetic. The first part of the article explores how smallpox inoculation was incorporated into existing medical thinking based on traditional humoral pathology. Inoculation was a new technology, but as it was perceived in the early eighteenth century, the innovation did not first and foremost concern the medical principles of the treatment. The second part of the article investigates arguments about why and when to inoculate: what kind of remedy was inoculation for eighteenth-century agents? The article concludes with a discussion on changes emerging towards the end of the century, and relates them to developments during the preceding decades rather than seeing them as inspired precursors of events and ideas to come. Keywords : Smallpox inoculation, Eighteenth century, Humoral pathology, Reluctance to changeWhat was the meaning of eighteenth-century smallpox inoculation? Traditional medical history used to present a continuity from inoculation to Jenner’s vaccine in 1798 and subsequently to the national vaccination programmes of the nineteenth and twentieth centuries, ending in total triumph with the global eradication of smallpox in the 1980s. ¹ The new medical history from the 1970s onwards has done much to change the general perspectives claiming a linear progressive development in medicine. ² As early as in 1985, Roy Porter argued the importance of studying beliefs about illness and health, situated in their historical contexts. ³ While Porter drew attention chiefly towards beliefs among the laity, recent studies in the history of technology and science have also pointed to the influence of cultural factors among scientists themselves. Not least can this be claimed to be relevant in the case of medicine, situated as it is between science and social practice. Ludmila Jordanova contrasts this modern interest in investigating meanings, beliefs and interest with traditional history of science and medicine, saying that ‘in a progressivist narrative, the search for truth was told in terms of blind alleys and right answers; the model was a journey, and the main emphasis was on content’. ⁴ She goes on to point out that few questions were asked about mediating processes, or about ‘how problems requiring explanations were defined’. ⁵ The new medical history, on the other hand, was, as Jordanova argues, shaped by a number of theoretical influences which may all be grouped as ‘social constructionist’. This implied a shifting of focus from the content of the ‘right’ answers to the processes by which knowledge – including scientific knowledge – is produced and negotiated. Jordanova describes this by saying that ‘between the material world and our representations of it there now appeared to be a space, which it was the job of historians (and sociologists and philosophers) to examine’. ⁶ This article will enter such a space, and ask how smallpox and smallpox inoculation were understood in the second part of the eighteenth century.The idea that smallpox could be conquered, even eradicated, was not a necessary companion to the new method when it was introduced in Europe. This potentiality only gradually emerged and was not clearly articulated until the end of the eighteenth century. The main focus of the present article will be the years approximately between 1750 and 1775. Often called the second phase of smallpox inoculation in Europe (after its introduction in the 1720s), this period saw important changes in the way inoculation was carried out. The method became both safer, simpler and less expensive than before. The changes made new ideas possible, but it is important that they were not initiated by the ideas and projects which they later inspired. It also would be overly simplistic to view changing understandings as mere reflections of improved method. The new ideas had more complex roots than technical improvements alone. This article will argue that the slowly changing understanding of the potentialities of inoculation was produced by an interaction between inoculation practice, more general medical theory and developments within probabilistic thinking and political arithmetic.Because the idea of the article is not to discuss the actual practice of inoculation, some issues that have figured prominently in historical research on inoculation will not be touched upon. This concerns the questions of mortality rates and population growth, as well as popular resistance against inoculation. Moreover, the article will discuss a period before the more extensive state initiatives to combat smallpox epidemics had been launched, and thus not go into the idea of public health as it emerged through such programmes. What rather is at stake in the following is the meaning of smallpox inoculation to its eighteenth-century advocates and practitioners. What was inoculation to them? As will appear from the following investigation, this question concerns the medical workings of the new remedy, but also its religious and ethical implications. The meaning of inoculation moreover relates to understandings of chance, luck, hazard and risk, and to the changing conceptualisation of the relation between the individual subject and the population at large.The method chosen to explore this is a close reading of influential texts on inoculation, produced in three different European countries. They represent voices in a public debate on why, when and, to some degree, how to inoculate.As a method of analysis, close reading insists on taking seriously what goes on in the text. The aim is not primarily to detect the intentions of the authors or the influence of their historical contexts, but to study texts as historical realities carrying meaning in themselves. The texts to be investigated here reflect how inoculation was spoken of, what kind of metaphors it was surrounded by, how disease and epidemics were conceptualised. Moreover, they provide the possibility of understanding something about the self-evident premises of the arguments. What is not said, what is not made an issue in these text – because it was unthinkable, or because it was self-evident? To understand the motives and ideas of eighteenth-century medical agents, studies of technology and medical practices alone are not sufficient. The ways the disease and its remedies were spoken of and turned into arguments of a public debate are equally important.The first part of the article explores how smallpox inoculation in Europe was incorporated into existing medical thinking based on traditional humoral pathology. Inoculation was a new technology, and radically so, but as it was perceived in the eighteenth century the radicality did not first and foremost concern the medical principles of the treatment. The middle part of the article investigates arguments as to why and when to employ the new technology. What kind of remedy was inoculation to mid-eighteenth century agents? What kind of situations made its use relevant, and what was the expected outcome? The article concludes with a discussion on changes that emerged towards the end of the century, relating them to developments during the preceding decades rather than seeing them as inspired precursors of events and ideas to come.The material for this study is taken from England, France and Denmark–Norway. England was the first country in Europe where inoculation was introduced from the Middle East, and also the country where it was most generally used. Comparing England to France, where inoculation never became common practice and powerful institutions like the Sorbonne even pronounced themselves against it, it appears obvious that even the arguments in favour of the method differed. One reason for this difference, as Andrea A. Rusnock has pointed out, was that in England the physicians themselves advocated the method, which made it possible to unite practical experience with theoretical argument. In France, local corporations controlled medical practice to a far greater extent, and most of them opposed inoculation for a longer period of time. Here the method was advocated by philosophes who were not physicians, or by physicians who were not French. ⁷ Both countries hold central positions in the history of European smallpox inoculation.Denmark, and not least its northern province Norway, represents a European periphery. The first inoculations in this twin monarchy appear to have taken place in Trondheim (Norway) in 1754. In the capital Copenhagen, a royal inoculation house was established in 1755, but met with little success and closed down after just five years. Apart from this, inoculation in Denmark–Norway seems to have occurred only sporadically and due to private and in some cases lay initiatives. ⁸   Pro-inoculation debate was strongly influenced by texts in English and French, some of which were read in the original, others translated. The earliest text on inoculation to have been published in Denmark–Norway was by J.-A. Butini, originally published in 1752 and translated from French in 1753. La Condamine’s internationally influential pamphlet appeared in Danish in 1755, one year after the French original. ⁹ The texts examined in this article are two medical treatises, written by the English physician J. Kirkpatrick and the Danish professor of medicine Chr. Friis Rottböll, respectively. ¹⁰ Together with a short article by the Swedish physician L. Montin, these texts discuss medical theory concerning smallpox and the effect of inoculation. ¹¹ The texts by the Swiss physicians J.-A. Butini and S.A.D. Tissot, the Italian Angelo Gatti and the English Thomas Dimsdale are manuals, giving instructions on how to carry out inoculation. ¹² They cite arguments in defence of the new technology, but do not enter into discussions on how it works. The texts by Cramer and Bredal, la Condamine, Tronchin and Smith, finally, all promote inoculation by explaining its advantages and also by answering the objections that were most commonly raised against it. ¹³ The aim of the investigation is not to elaborate on national differences, but rather to show how the inoculation debate was fairly international. Influential texts circulated widely and crossed national borders. Pro-inoculation arguments were quoted extensively, and long passages of texts by one author could be incorporated into that of another. Works advocating inoculation constituted an intertextual network, explicitly and implicitly referring to each other. In this network, the three countries of this investigation held different roles. All produced texts and arguments that circulated. The English and French texts had international influence, the Danish and Norwegian probably merely national. Including material from this part of Europe nonetheless adds to our general knowledge about the history of inoculation. It demonstrates the range and significance of ideas and literature from the larger countries, but it also shows that the time lag was small. Despite their role mainly as receivers of ideas, the physicians and intellectuals in the northern periphery were well oriented, quick to import novelties and to relate themselves to international debates.All the texts have been influential. They set the debates and shaped opinion, though in different contexts. Some of their authors, like Dimsdale, la Condamine and Tissot, were men of international renown. As a general trait, it may also be worth noting that medical men were not the only ones to contribute to the inoculations debate. Other men of letters and enlightened philosophy took part, which is an indication that inoculation was not only considered to be a matter of medicine but also concerned the welfare of society at large. On the other hand, it is equally interesting to note that no statesmen or men of political influence are to be found among the authors. In all three countries there were only few and mostly weak attempts at organising larger public programs of inoculation in this period, and they do not seem to have resulted in texts that can be taken to indicate pro-inoculation engagements or ideas on the official level of the state.     

Modern Health Worries, Subjective Health Complaints, Health Care Utilization, and Sick Leave in the Norwegian Working Population

Background

Modern health worries (concerns about aspects of modern life affecting health) heve been associated with subjective health complaints and health care utilization.

Purpose

The aim of this study was to investigate the association between modern health worries (MHW) and subjective health complaints (SHC), health care utilization, and sick leave related to such complaints in the Norwegian working population.

Methods

A sample of the Norwegian working population (N?=?569) answered a questionnaire which included the Subjective Health Complaints Inventory and a Norwegian version of the Modern Health Worries Scale.

Results

Ninety-one percent of the participants reported at least one complaint in the past 30 days, and 96 % of the participants reported concerns for at least one of the items in the MHW scale. Women reported significantly more and more severe complaints compared to men and significantly more concern about aspects of modern life affecting health. Participants who reported a high level of MHW showed nearly twice the risk of reporting a high level of SHC (odds ratio (OR)?=?1.83; 95 % confidence interval (CI)?=?1.30–2.71; p?=?0.001), and they showed twice the risk for self-certified sick leave related to SHC (OR?=?2.04; 95 % CI?=?1.01–3.92; p?=?0.048). High levels of MHW showed no significant association with health care utilization or doctor-certified sick leave.

Conclusions

Subjective health complaints and concerns about aspects of modern life affecting health are very common, even among healthy workers. Women have more complaints and more concerns compared to men. Within the health care system, it may be advantageous to pay close attention to the association between high levels of MHW and high levels of SHC.     

Are the High Hip Fracture Rates Among Norwegian Women Explained by Impaired Bone Material Properties?

Hip fracture rates in Norway rank among the highest in the world, more than double that of Spanish women. Previous studies were unable to demonstrate significant differences between the two populations with respect to bone mass or calcium metabolism. In order to test whether the difference in fracture propensity between both populations could be explained by differences in bone material quality we assessed bone material strength using microindentation in 42 Norwegian and 46 Spanish women with normal BMD values, without clinical or morphometric vertebral fractures, no clinical or laboratory signs of secondary osteoporosis, and without use of drugs with known influence on bone metabolism. Bone material properties were assessed by microindentation of the thick cortex of the mid tibia following local anesthesia of the area using the Osteoprobe device (Active Life Scientific, Santa Barbara, CA, USA). Indentation distance was standardized against a calibration phantom of methylmethacrylate and results, as percentage of this reference value, expressed as bone material strength index units (BMSi). We found that the bone material properties reflected in the BMSi value of Norwegian women was significantly inferior when compared to Spanish women (77 ± 7.1 versus 80.7 ± 7.8, p < 0.001). Total hip BMD was significantly higher in Norwegian women (1.218 g/cm² versus 0.938 g/cm², p < 0.001) but regression analysis revealed that indentation values did not vary with BMD r² = 0.03 or age r² = 0.04. In conclusion Norwegian women show impaired bone material properties, higher bone mass, and were taller than Spanish women. The increased height will increase the impact on bone after falls, and impaired bone material properties may further enhance the risk fracture after such falls. These ethnic differences in bone material properties may partly explain the higher propensity for fracture in Norwegian women. © 2015 American Society for Bone and Mineral Research.     

Advanced Electrocardiogram Analysis in the Amitriptyline‐poisoned Pig Treated with Activated Charcoal Haemoperfusion

Coated activated charcoal haemoperfusion (CAC‐HP) does not reduce the plasma concentration in amitriptyline (AT)‐poisoned pigs. The aim of this non‐blinded, randomized, controlled animal trial was to determine if CAC‐HP reduces the pathological ECG changes caused by AT poisoning. Fourteen female Danish Landrace pigs (mean weight 27.7 kg, range 20–35 kg (CAC‐HP) and 24.4 kg, range 18–30 kg (control group, CG), n = 7 in each group) were included. After randomization, the pigs were anaesthetized and intravenously poisoned with AT. The intervention group underwent 4 hr of CAC‐HP plus standard care (oral activated charcoal). Intervention was compared to standard care alone. From each pig, a 12‐lead ECG and haemodynamic variables were obtained at baseline, at full AT loading dose, before and during CAC‐HP. Baseline ECG variables (RR, PR, QRS, QTc, QTp, QTe, TpTe and TpTe/QT) for lead II, v2 and v5 were not significantly different (F = 0.035–0.297, p‐values 0.421–0.919). Differences within groups over time and between groups were tested by anova repeated measures. For all variables, the time‐plus‐group level of significance revealed a p‐value > 0.05. Severe cardiovascular arrhythmias occurred in both groups with 3 in the CAC‐HP group versus 1 incident with premature death in the CG. The attenuating effect of CAC‐HP to orally instilled activated charcoal alone on AT‐induced ECG alterations did not differ significantly. We conclude that the use of modern CAC‐HP as an adjunctive treatment modality in AT‐poisoned pigs is inadequate.