Variolation
Based on Wikipedia: Variolation
In 1718, somewhere in the heart of Constantinople, a five-year-old English boy named Edward Montagu had dried smallpox scabs rubbed into a scratch on his arm. His mother, Lady Mary Wortley Montagu, watched the procedure with something approaching hope. Three years earlier, she had survived smallpox herself, but the disease had left her face permanently scarred. Her brother had not been so lucky—he died from it in 1713. Now she was betting her son's life on a practice she had learned from elderly Turkish women: deliberately infecting a child with smallpox to save him from dying of it later.
This was variolation. And it worked.
The Calculated Gamble
Here is the terrible arithmetic that made variolation rational: if you caught smallpox naturally, you had roughly a thirty percent chance of dying. Three in ten. But if someone carefully introduced a small amount of smallpox material into a scratch on your skin—rather than letting you breathe it in through your nose and lungs—your odds of dying dropped to about one or two percent. Still a gamble, but dramatically better odds.
The difference came down to how the virus entered your body. Smallpox normally spread through the air, infecting the mouth, nose, and respiratory tract before rampaging through the lymphatic system and spreading everywhere. But when the virus entered through a small wound in the skin, the infection tended to stay localized. You would still develop pustules. You would still feel miserable for two to four weeks. But the infection was usually milder, and when you recovered, you were immune for life.
Think of it like the difference between a house fire that starts in the basement and spreads through the ventilation system versus one that starts in a single trash can by the back door. Same fire, same potential for destruction, but the second one is much easier to contain.
Blowing Smallpox Up Your Nose
The Chinese figured this out centuries before Lady Montagu ever set foot in Constantinople. The oldest documented use of variolation dates back to sixteenth-century China, and some sources push it even earlier, to the eleventh century.
The Chinese method was different from what Lady Montagu witnessed. Instead of rubbing infected material into a scratch, they practiced what was called "nasal insufflation"—essentially blowing powdered smallpox scabs up the patient's nostrils. The procedure became highly ritualized. Practitioners used silver blowpipes. They used the right nostril for boys and the left for girls. And they were very particular about their source material.
Not just any smallpox scabs would do. Doctors selected mild cases as donors, understanding that the severity of the source infection might influence the severity of the induced one. They also let the scabs dry out for a considerable time before using them. Fresh scabs were more likely to cause a full-blown, dangerous infection. The standard recipe involved grinding three or four dried scabs into powder, sometimes mixing them with a grain of musk, then binding the mixture in cotton before packing it into the blowpipe.
By the eighteenth century, two competing schools of thought had emerged. The Sung-chiang school insisted on using scabs only from the mildest possible cases. The Hu-chou school was less picky about donor selection. The imperial editors favored the Hu-chou approach, and the Kangxi Emperor himself was convinced enough to have both his children and his regular troops variolated.
Reports of the Chinese practice reached the Royal Society in London in 1700. Two separate accounts came in—one from a doctor who had heard about it from an East India Company employee stationed in China, another from a physician named Clopton Havers.
Nothing happened. The reports were filed away and forgotten for two decades.
The Indian Subcontinent and the Question of Origins
India has also been proposed as a possible birthplace of variolation, though the evidence is murkier. Two eighteenth-century accounts describe itinerant Brahmins performing inoculations. One account from 1731 claimed the practice had been "first performed by Dununtary a physician of Champanagar" about 150 years earlier—though "Dhanvantari" was also the name of the Hindu god of medicine, which makes the attribution somewhat suspect.
By 1768, there is clearer evidence that variolation was being practiced in Bengal. A letter from that year describes two methods: one involved rubbing dried scabs from the previous year into small needle pricks on the arm, while the other had patients swallow the dried scabs mixed with sugar in a pleasant-tasting liquid. The practitioners were known as Tikadars—and the term "tika" is still used today to mean vaccination in many Indian languages.
Whether variolation was truly ancient in India or was introduced later remains contested. The original Sanskrit texts that supposedly describe the practice have never been found. Some historians have suggested that nineteenth-century claims about ancient Indian variolation were actually propaganda—texts written by colonial officers in Sanskrit and local languages to convince pious Indians to accept Jenner's new vaccination technique while abandoning older practices.
Buying the Smallpox
Some of the most vivid descriptions of variolation come from Sudan, where the practice had been long established by the time European observers arrived in the late eighteenth and early nineteenth centuries.
In central Sudan, in the region of Sennar, women practiced something called "Tishteree el Jidderi"—literally, "buying the smallpox." Here is how it worked: a mother with an unprotected child would visit the house of a family with a newly infected child. She would tie a cotton cloth around the sick child's arm. Then she would haggle with the sick child's mother over the price of each pustule. When they reached an agreement, she would take the cloth home and tie it around her own child's arm.
The commercial framing was not incidental. This was a transaction, with all the negotiation and exchange of value that implies. Some variations of the practice involved bringing gifts to the donor family instead of cash payment.
A second Sudanese method, called "Dak el Jedri" or "hitting the smallpox," more closely resembled what was practiced in the Ottoman Empire. Fluid was collected directly from a smallpox pustule and rubbed into a cut in the patient's skin. This technique spread widely through Africa and may have traveled along caravan routes into Turkey and Greece, carried by merchants and pilgrims.
The Welsh Connection
Before Lady Montagu brought variolation to fashionable London society, the practice may have already been quietly happening in Wales. Letters from physicians published in 1722 indicated that variolation had been used near the Welsh port of Haverfordwest since around 1600—more than a century earlier. Another reference appears in the writings of Thomas Bartholin in 1675.
How it arrived in Wales, and whether it developed independently or was imported from elsewhere, remains unclear. But it serves as a reminder that folk practices often exist for generations before elite medicine discovers them.
Lady Montagu's Campaign
When Lady Montagu returned to England, she did not keep what she had learned quiet. In 1721, she had her four-year-old daughter variolated in the presence of physicians from the Royal Court. Both her children's procedures proved successful.
That same year, a more dramatic demonstration took place. Dr. Charles Maitland, who had supervised young Edward Montagu's variolation in Constantinople, conducted an experiment on six condemned prisoners in Newgate Prison. The deal was straightforward: submit to variolation, then be deliberately exposed to smallpox afterward. Survive, and you go free.
All six survived. The experiment attracted the attention of the royal family, who helped promote the procedure throughout England.
Yet variolation was not without its victims. In 1783, Prince Octavius—the eighth son of King George III—died from the procedure. He was four years old. The very treatment meant to save children from smallpox had killed a prince.
The Problem of Simplicity
One of variolation's greatest strengths was also its greatest weakness: it was simple. Too simple, in fact, for the comfort of professional physicians.
The basic procedure—rub infected material into a scratch—required no formal medical training. Elderly Turkish women had been doing it for generations. This created a problem for doctors who wanted to maintain their monopoly on medical treatments.
Their solution was to make the procedure more complicated. Doctors began insisting on severe bloodletting before variolation, draining patients to the point of faintness to "purify" the blood and prevent fever. They favored deep incisions rather than shallow scratches. These additions had no medical benefit—they actually made the procedure more dangerous—but they did make it look like something only a trained professional could perform.
The Sutton Revolution
The most successful variolators in English history were not aristocratic physicians but a family of entrepreneurs from Suffolk: the Suttons.
The patriarch, Robert Sutton, was a surgeon who had a personal stake in improving the procedure. In 1757, variolation failed on one of his own sons. This failure drove him to develop what he called "A New Method of Inoculating for Small-Pox," which he began advertising in 1762.
Sutton kept his method secret, sharing it only with his three sons. The mystery surrounding their technique was itself a marketing tool—people paid premium prices to learn what the Suttons knew that others did not. The family built a network of variolation houses and clinics, even offering franchises to other practitioners in exchange for a share of profits and a promise to keep the secret.
By 1770, the Suttons had treated over 300,000 customers.
When Daniel Sutton, the eldest son, finally published the family secret in his 1796 book "The Inoculator," the revelation was almost anticlimactic. The Sutton method involved three things: use a shallow scratch rather than a deep incision, carefully select donors who had only mild cases of smallpox, and skip the bloodletting and purging that other doctors insisted upon.
In other words, the secret was simply to do the procedure correctly and not add unnecessary complications. The Suttons had succeeded by ignoring the harmful innovations that professional physicians had introduced.
Johnnie Notions and the Shetland Islands
Perhaps the most remarkable variolator was not a trained physician at all but a self-taught craftsman from Shetland, Scotland, known by the nickname "Johnnie Notions."
John Williamson had only an elementary education and no formal medical background. But during the late eighteenth century, he independently developed a variolation technique and administered it to approximately 3,000 people in Shetland. According to oral tradition, he never lost a single patient.
His method was idiosyncratic and meticulous. First, he would collect smallpox pus. Then he would dry it using peat smoke—which he believed reduced the virus's virulence—and bury it in the ground along with camphor, which has antibacterial properties that would prevent the material from decomposing. Some accounts say he spread the matter between sheets of glass before burial. He would store this material for up to seven or eight years before using it, believing that age further weakened the virus.
When administering the variolation, Notions used a knife he had made himself to create an intradermal incision—one that did not draw blood. He would insert a tiny amount of the aged material, immediately cover the wound with the patient's own skin, and apply a cabbage leaf as a bandage.
Unlike the quack doctors of his era, Notions did not prescribe any particular treatment regimen during recovery. No "hot-treatment" involving heating the patient before a fire and denying them fresh air. No additional medicines. He simply let the body do its work.
His success rate suggests he understood something essential that more educated practitioners had obscured with their elaborate additions: the procedure itself was doing the work, and most of what doctors added only made things worse.
The End of Variolation
Variolation worked, but it had a fundamental problem: the people who were variolated could spread real smallpox to others. A variolated patient was treated as fully infectious until their rash cleared, which meant weeks of quarantine. And occasionally, the induced infection was not mild at all—it killed the patient and potentially started new outbreaks.
In 1796, the same year Daniel Sutton published the family secret, a country doctor named Edward Jenner demonstrated something remarkable. He showed that infection with cowpox—a related but much milder disease that affected cattle—could also protect against smallpox, without any risk of causing smallpox itself.
This was vaccination, named after "vacca," the Latin word for cow. By 1800, the term was in wide use, and "variolation" was coined specifically to distinguish the older, riskier practice from Jenner's safer alternative.
Variolation had been a brilliant insight: that a controlled, mild infection could protect against a deadly one. It had saved countless lives over centuries, from sixteenth-century China to eighteenth-century London to the remote Shetland Islands. But it was always a calculated gamble, always carrying the risk of the very disease it sought to prevent.
Vaccination kept the insight while eliminating the gamble. And from that foundation—the idea that you could train the immune system with something safe to protect against something deadly—would eventually grow the entire field of immunization that protects billions of people today.
The elderly Turkish women who taught Lady Montagu, the Chinese physicians with their silver blowpipes, the Sudanese mothers haggling over the price of pustules, Johnnie Notions with his seven-year-old peat-smoked scabs—none of them had microscopes or germ theory or any understanding of why their methods worked. But they had figured out something essential about how to protect human beings from one of history's most terrifying diseases. They had learned, through centuries of observation and experimentation, how to turn smallpox against itself.