variolation variolation variolation was the method of inoculation first used to immunize individuals against smallpox (variola) with material taken from a patient or a recently variolated individual, in the hope that a mild, but protective, infection would result. variolation is no longer used today. it was replaced by the smallpox vaccine, a safer alternative. this in turn led to the development of the many vaccines now available against other diseases. the procedure was most commonly carried out by inserting/rubbing powdered smallpox scabs or fluid from pustules into superficial scratches made in the skin. the virus was normally spread through the air, infecting first the mouth, nose, or respiratory tract, before spreading throughout the body via the lymphatic system. in contrast, infection of the skin usually led to a milder, localized infection, but, crucially, still induced immunity to the virus. the patient would develop pustules like those caused by naturally acquired smallpox. eventually, after about two to four weeks, these symptoms would subside, indicating successful recovery and immunity. the method was first used in china, india, parts of africa and the middle east before it was introduced into england and north america in the 1720s in the face of some opposition. however, inoculation had been reported in wales since the early 17th century. terminology the terminology used to describe the prevention of smallpox can cause confusion. in 18th-century medical terminology, inoculation refers to smallpox inoculation. confusion is caused by writers who interchange variolation and vaccination through either mistranslation or misinterpretation. the term variolation refers solely to inoculation with smallpox virus and is related to but not interchangeable with vaccination. the latter term was first used in 1800 soon after edward jenner introduced smallpox vaccine derived from cowpox, an animal disease distinct from smallpox. the term variolation was then used from the 19th century to avoid confusion with vaccination. most modern writers tend to refer to smallpox inoculation as variolation throughout without regard for chronology, as is used here. further confusion was caused when, in 1891, louis pasteur honoured jenner by widening the terms vaccine/vaccination to refer to the artificial induction of immunity against any infectious disease. inoculation refers to intentionally exposing an individual to a virus, bacterium, other pathogen, or artificial vaccine that may induce active immunity, and inoculation can be done by any suitable route of administration. many familiar vaccines are injected intramuscularly or swallowed. the term "inoculation" entered medical english through horticultural usage meaning to graft a bud (or eye) from one plant into another. it is derived from the latin in + oculus (eye). origins china the chinese practiced the oldest documented use of variolation, dating back to the fifteenth century. they implemented a method of "nasal insufflation" administered by blowing powdered smallpox material, usually scabs, up the nostrils. various insufflation techniques have been recorded throughout the 16th and 17th centuries within china.: 60 according to such documentation, mild smallpox cases were selected as donors in order to prevent serious attack. the technique used scabs that had been left to dry out for some time. fresh scabs were more likely to lead to a full-blown infection. three or four scabs were ground into powder or mixed with a grain of musk and bound in cotton. infected material was then packed into a pipe and puffed up the patient's nostril. the practice of variolation is believed to have been ritualized by the chinese. the blowpipe used during the procedure was made of silver. the right nostril was used for boys and the left for girls.: 45 variolated cases were treated as if they were as infectious as those who had acquired the disease naturally. these patients were subsequently kept apart from others until the rash had cleared. in the 18th century, the practice of using scabs from epidemic patients was seen as beneficial by some, but others were convinced of its danger; emperor kangxi, however, approved of it. two reports on the chinese practice were received by the royal society in london in 1700; one by dr. martin lister who received a report by an employee of the east india company stationed in china, and another by the physician clopton havers, but no action was taken. india india has been suggested as another possible origin for the spread of variolation into europe, particularly the ottoman empire and wales. there are two accounts from the 18th century of inoculations being performed by itinerant brahmins: oliver coult in 1731 wrote that it had been "first performed by dununtary a physician of champanagar" about 150 years before that time (dhanvantari being the name of the hindu god of medicine, and a common name among physicians), and john zephaniah holwell in 1768 wrote of its being practiced for many hundreds of years. aspects of these accounts have been called into question, but reportedly, by 1768 inoculation was being practiced in bengal. the doctors who performed this procedure were known as tikadars. the term tika is still in use now to mean 'vaccination' in many indian languages. sudan similar methods were seen through the middle east and africa. two similar methods were described in sudan during the late eighteenth and early nineteenth centuries. both had been long established and stemmed from arabic practices. tishteree el jidderi ('buying the smallpox') was a practice seen within the women of sennar in central sudan.: 61 a mother of an unprotected child would visit the house of a newly infected child and tie a cotton cloth around the ailing child's arm. she would then haggle with the child's mother over the cost of each pustule. when a bargain was struck, the woman would return home and tie the cloth around her own child's arm. variations of this practice included bringing gifts to the donor. the second method was known as dak el jedri ('hitting the smallpox'),: 61 a method similar to that used in the ottoman empire and eventually transported into england. fluid was collected from a smallpox pustule and rubbed into a cut made into the patient's skin. this practice spread more widely through africa. it may have also traveled with merchants and pilgrims along the middle-eastern caravan routes into turkey and greece.: 15 western europe letters from physicians in wales published in 1722 indicated the local use of variolation from as early as 1600 near the welsh port of haverfordwest. another reference to variolation is by thomas bartholin in 1675. after coming across the practice in constantinople, the physician emanuel timonius wrote a letter describing the method in detail which was later published in the philosophical transactions in 1714 and read to the royal society. the report caught the attention of a bostonian minister, cotton mather who mentions of an encounter in 1707 with a garamante from libya named onesimus, mather said the society that onesimus was from, already had a practice of an operation that would have "given him something of the smallpox and would forever preserve him from it". benjamin colman, another minister also mentions of inoculation practices from africa. while the wife of a british diplomat to the ottoman empire, lady mary montagu, said variolation was widely practiced in the ottoman empire. lady montagu lady mary wortley montagu had lost her brother to smallpox in 1713. in 1715 she contracted the disease herself. although she survived, she was left with severe facial scarring. while in turkey she came across the process of variolation as it was introduced and published in constantinople by two doctors, emmanuel timoni and iacob pylarino. she first mentioned variolation in the famous letter to her friend, sarah chiswell, in april 1717.: 55 in which she enthusiastically recounted the process, which in constantinople was most commonly administered by experienced elderly women. in 1718, she had the procedure conducted on her five-year-old son, edward montagu. the procedure was supervised by the embassy doctor charles maitland. on her return to england, she had her four-year-old daughter variolated in the presence of physicians of the royal court in 1721.: 90 both variolations proved successful. later on that year maitland conducted an experimental variolation of six prisoners in newgate prison in london. in the experiment, six condemned prisoners were variolated and later exposed to smallpox with the promise of freedom if they survived.: 45 the experiment was a success, and soon variolation was drawing attention from the royal family, who helped promote the procedure throughout england. however, variolation caused the death of prince octavius of great britain, eighth son and thirteenth child of king george iii in 1783. engraving of lady mary wortley montagu by samuel freeman, after a portrait by sir godfrey kneller despite opposition, variolation established itself as a mainstream medical treatment in england. part of its success was founded on statistical observation, which confirmed that variolation was a safer alternative to contracting smallpox naturally, strengthened by the assumption that it protected against the disease for life. the major faults of variolation lay in its simplicity. doctors sought to monopolize the simple treatment by convincing the public that the procedure could only be done by a trained professional. the procedure was now preceded by a severe bloodletting, in which the patient was bled, often to faintness, in order to 'purify' the blood and prevent fever. doctors also began to favour deep incisions, which also discouraged amateurs.: 18 the suttonian method the main proponents of the english variolation movement were the suttons, a family of physicians who would revolutionize the practice. the patriarch, robert sutton, was a surgeon from suffolk. in 1757 the procedure failed on one of his sons.: 20 he sought a new method in which the procedure would become as mild as possible. by 1762 he began advertising "a new method of inoculating for small-pox." sutton kept his method a secret and shared it only with his three sons. the mystique and effectiveness behind this new method helped to promote their business, which soon became very successful. they established a network of variolation houses and clinics and offered franchises to other variolators for a share of the profits, on condition that the secret would not be revealed. by 1770, the suttons had treated over 300,000 satisfied customers.: 94 daniel, the eldest of the sutton sons, eventually revealed the family secret in his book the inoculator, published in 1796.: 22 the success of their method lay in a shallow scratch, careful selection of only mildly affected donors, and no bleeding or extreme purging. although the renown of the suttons gradually faded after this revelation, the family's lasting impression would remain for generations. thomas nettleton (1683–1748) was a precursor of the suttons around 1722. other prominent english variolators included thomas dimsdale, who published accounts of his method in 1769 and 1781; william woodville, appointed director of the london smallpox and inoculation hospital in 1791, who published a history of variolation in 1796; and john haygarth, who published an ambitious plan to exterminate smallpox in 1783. johnnie notions john williamson, more commonly known by the nickname johnnie notions, was a self-taught: 571 physician from shetland, scotland, who independently developed and successfully administered a variolation for smallpox to thousands of patients in shetland during the late 18th century. despite having only an elementary education and no formal medical background,: 208 the effectiveness of the treatment he devised yielded an extremely high success rate, resulting in the immunisation of approximately 3,000 people and the saving of many lives, which had a significant effect on the demographics of the shetland population at the time.: 402 he is reputed to have not lost a single patient.: 571 notions would first collect smallpox pus. he would then dry it using peat smoke (which was believed to lessen the virus's virulence),: 401 and bury it in the ground with camphor: 571 (which has anti-bacterial properties, preventing the matter from decomposing).: 401 oral history indicates the matter was spread between sheets of glass before burial. it would be kept in this state for up to seven or eight years to reduce its virulence before being administered to a patient.: 571 by using a knife (which notions made himself) he would incise into the patient's arm intradermally (without drawing blood), insert a small amount of the matter, and immediately cover the incision with the patient's skin, before using a cabbage leaf as a plaster.: 571 in contrast to contemporaneous