From the time that I entered into the practice of medicine, and saw the
danger to which the generality of those who had the small-pox in the
natural way were exposed, I could not but sincerely wish, with every
sensible person of the faculty, that Inoculation might become general.
A considerable share of employment in this branch of my profession
has for upwards of twenty years occurred to me; and altho’ I have
been so fortunate as not to lose a patient under inoculation, except
one child, about fourteen years ago, who after the eruption of a few
distinct pustules died of a fever, which I esteemed wholly independent
of the small-pox, yet I must acknowledge that in some cases the
symptoms have cost me not a little anxiety for the event.
Nor have the subsequent effects of this practice always been so
favourable as one could wish; and tho’ far from equalling those which
too often follow the natural small-pox; either in respect to difficulty
or number, yet they sometimes gave no small uneasiness to the operator.
It cannot likewise, it ought not to be concealed, that some of the
inoculated have died under this process, even under the care of very
able and experienced practitioners. But this number is so small, that,
when compared with the mortality attending the natural small-pox, it is
reduced almost to a cypher.
These circumstances, however, tended to discourage the operation in
some degree. Practitioners were cautious of urging a process, of whose
event they could not be certain: and parents, who were sensible enough
to observe, that though the chance was greatly in their favour, yet a
blank might cast up against them, engaged in it with hesitation.
Humanity, as well as a wish to promote the honour and advantage of the
art I profess, made me ever attentive to the improvement of this part
of my employment. Dissatisfied with the common methods, I had carefully
attended to the circumstances that seemed to contribute to the good or
ill success of this practice, in the course of my own business, as well
as to the best information I could get of the success of others.
Many facts had induced me to think that regimen, preparation, and
management would do much: that as the disease was of an inflammatory
kind, a cooling regimen must certainly for the most part be reasonable.
Some faint essays were made to try how far this sentiment might be
just. But those who are the best acquainted with the first aphorism of
Hippocrates, will be the first in justifying a cautious procedure,
where the object is no less than the life of an individual.
In this situation I first heard, and with the utmost satisfaction,
that in some parts of the nation, a new and more successful method
of inoculating was discovered, than had hitherto been practised. The
relators gave incredible accounts of the success; which was the more
marvellous, as the operators were chiefly such, as, by report, could
lay but little claim to medical erudition.
Knowing that improvements, which would do honour to the most elevated
human understandings, are sometimes stumbled upon by men of more
confined abilities; and that in medicine, as well as in every other
circumstance in life, it is our duty to avail ourselves as much as
possible of all discoveries tending to the common benefit, I embraced
every _just opportunity_ of informing myself of facts, circumstances,
and events, that either public fame, or more precise relations,
brought to me. I use the term _just opportunity_, because, if I am not
misinformed, endeavours have been used, inconsistent with equity and
candour, to rob those who are intitled to our gratitude for assisting
us in this important process, of that share of private emolument which
is their due, let their title to the discovery be ever so paradoxical.
To expose patients, even in the inoculated small-pox, to all weathers,
was a thing unheard of. To permit them through the whole progress
of the disease to go abroad, and follow their usual vocations, and
that they should neither suffer any present evil, nor experience any
disagreeable consequences, was still more surprizing; yet an infinite
number of instances have confirmed all this; and some of these
instances will appear in the sequel of this performance.
The design of this treatise is to bring the practice still one step
nearer to perfection, and lessen the ravages of a distemper, which is
not a native of Britain, but, like the plague, has been imported from
a foreign country, and demands the exertion of all the powers we are
possessed of, either to exterminate it from amongst us, which perhaps
is not practicable, or to render it less unsafe, if not wholly without
difficulty or danger.
The following directions for this purpose, are the result of an
extensive practice: and if a strong persuasion of the truth of what he
writes, founded on repeated trials and impartial observations, should
have led the author to express himself in a very sanguine manner, the
future experience of others, he trusts, will be his justification.
Hertford, 1. Nov.
1766.
Of the AGE, CONSTITUTION, and SEASON of the Year proper for INOCULATION.
Before I proceed to describe the regimen and preparatives, it may
not be improper to mention what has occurred to me in respect to the
most suitable age and constitution for inoculation; and likewise what
seasons seem to be more or less favourable for the practice.
In regard to age; where it is left to my choice, I decline inoculating
children under two years old. I know the common practice is against
me in this particular; but my reasons for rejecting such are founded
on observation and experience. I have, indeed, lately inoculated many
under this age, at the pressing entreaties of their parents, and they
have all done well. But it must be considered, that young children are
exposed to all the hazards of dentition, fevers, fluxes, convulsions,
and other accidents, sufficiently difficult in themselves to manage in
such tender subjects; insomuch that scarce two in three of all that are
born, live to be two years old, as is demonstrable from the Bills of
Mortality.
Besides, convulsive paroxysms often accompany the variolous eruptive
fever in children; and though generally looked upon in no unfavourable
light, as often preceding a distinct kind of small-pox, yet they are
at all times attended with some degree of danger; nay, some, it is
well known, have expired under them; while others, who have struggled
through with great difficulty, have been so debilitated, and their
faculties so impaired, that the effects have been perceptible during
the remaining part of their lives.
And even admitting the eruption to be favourable, and not attended
with any such alarm, yet should a larger number of pustules than
usual appear, or any untoward symptom happen, and require medical
help, the unhappy sufferer is much too young to be prevailed on to
take unpalatable medicines, or submit to other necessary measures,
by persuasions, menaces, or bribes. I have often been present at
afflicting scenes of this nature; and have reason to think that many
children have died of the small-pox in the natural way, merely from the
impossibility of prevailing upon them to comply with what was proper,
in cases where little or no danger was discoverable, either from the
number or species of the pustules, the degree of fever, or any other
apparent cause.
It must likewise be taken into consideration, that young children have
usually a larger share of pustules from inoculation, than those who are
advanced a little farther in life; and that under this circumstance
many have died; and the proportion of these, so far as I can learn,
is too great to encourage a continuance in the inoculation of young
children: so that it seems most prudent to wait till this dangerous
period be over, especially as its duration is so short, that the
danger of their receiving the small-pox therein in the natural way is
very little; and it is at this time much more easy to preserve them
from it, than when they are left more to themselves, and may be more in
the way of infection. But children above this period may be inoculated
more freely; nor does there appear any reason to exclude healthy adults
of any age; persons of seventy having passed through this process with
the utmost ease, and without occasioning the least painful apprehension
for the event.
In respect to constitution, greater liberties may be taken than have
heretofore been judged admissible: persons afflicted with various
chronic complaints, of scrophulous, scorbutic, and arthritic habits;
persons of unwieldy corpulency, and of intemperate and irregular lives,
have all passed through this disease, with as much ease and safety as
the most temperate, healthy, and regular. But those who labour under
any acute or critical diseases, or their effects, are obviously unfit
and improper subjects. So likewise are those where there are evident
marks of corrosive acrimonious humours, or where there is a manifest
debility of the whole frame, from inanition, or any other cause: all
these should be treated in a proper manner previous to the introduction
of this disease. Constitutions disposed to frequent returns of
intermittents, seem likewise justly exceptionable; especially as the
preparatory regimen may in some habits increase this tendency. I have
known, however, instances of severe ague fits attacking persons between
the insertion of the matter and the eruption of the pock, and even
during maturation; when the Peruvian bark has been given liberally and
with success; the principal business, in the mean time, suffering no
injury or interruption.
Among the circumstances generally considered as more or less propitious
to inoculation, the season of the year has hitherto been deemed a
matter of some importance. Spring and autumn, for the most part, have
been recommended, as being the most temperate seasons; the cold of
winter, and the summer heats, having been judged unfavourable for this
process. But experience does not justify these opinions; for according
to the best observation I have been able to make, inoculated persons
have generally had more pustules in spring than at any other time of
the year; and epidemic diseases being commonly most frequent in autumn,
especially fluxes, intermittents, and ulcerated sore throats (all which
are liable to mix more or less with the small-pox) the autumn, upon
this account, does not seem to be the most favourable season in general.
My opinion is, that considering the surprizing and indisputable
benefits arising at all times to patients in the small-pox, from the
free admission of fresh cool air and evacuations (which will appear
from some cases hereafter subjoined) we may safely inoculate in
all seasons, provided care be taken to screen the patients as much
as possible from heat in summer, and to prevent them from keeping
themselves too warm, and too much shut up, as they are naturally
disposed to do, from the weather in winter. And it is well known, that
many have been inoculated in the depth of winter, and some during the
greatest heat in summer, without suffering any injury or inconvenience
from either.
When seasons, however, are marked with any peculiar epidemics, of such
a kind especially as may render a mild disease more untractable, it
may perhaps be most prudent not to inoculate while such diseases are
prevalent.
An eminent physician of my acquaintance in London, at that time in
considerable business, informed me that in the year 1756 the small-pox
were very rife, in the summer of that year especially. That in most of
them the throat was so much affected, that about the seventh day from
the eruption, when they ought to have taken liquors in abundance, they
could not swallow a drop. The ptyalism was in the mean time copious;
and the kind being for the most part confluent, they died on the tenth
or eleventh day; and those who sunk under this distemper (who were by
much the majority) all suffered from this cause. This instance is only
given to shew the necessity of regarding the general state of epidemics
when we go into this operation; and to excite those who are friends to
this most beneficial discovery, to use every means in their power to
provide against a single instance of ill success.
Of the PREPARATION.
In directing the preparatory regimen, I principally aim at these
points: to reduce the patient, if in high health, to a low and more
secure state; to strengthen the constitution, if too low; to correct
what appears vitiated, and to clear the stomach and bowels, as much as
may be, from all crudities and their effects. With this view, I order
such of my patients as constitute the first class, and who are by much
the majority, to live in the following manner: to abstain from all
animal food, including broths, also butter and cheese, and from all
fermented liquors, excepting small beer which is allowed sparingly, and
from all spices, and whatever possesses a manifest heating quality.
The diet is to consist of pudding, gruel, sago, milk, rice-milk,
fruit-pies, greens, roots, and vegetables of all the kinds in season,
prepared or raw. Eggs, though not to be eaten alone, are allowed in
puddings, and butter in pie-crust; the patients are to be careful
that they do not eat such a quantity as to overload their stomachs,
even of this kind of food. Tea, coffee, or chocolate are permitted for
breakfast, to those who choose or are accustomed to them.
In this manner they are to proceed about nine or ten days before the
operation; during which period, at nearly equal distances, they are
directed to take three doses of the following powder, either made into
pills, or mixed with a little syrup or jelly, at bed-time; and a dose
of Glauber’s salt, dissolved in thin water-gruel, each succeeding
morning.
The powder is composed of eight grains of calomel, the same quantity of
the compound powder of crabs claws, and one eighth part of a grain of
emetic tartar. Instead of emetic tartar, I have sometimes substituted
two grains of precipitated sulphur of antimony. In order to facilitate
the division of the doses, a large quantity is prepared at once, and
great care taken that the mixture is well performed.
This quantity is usually sufficient for a healthy strong man; and the
dose must be lessened for women or children, according to their age and
strength, as well as for persons advanced in years.
The first dose is commonly ordered at the commencement of the course,
the second, three or four days after, and the third, about the eighth
or ninth day; and I choose to inoculate the day after the last dose
has been taken. On the days of purging, broths are allowed, and the
patients are desired to abstain from unprepared vegetables.
What has hitherto been said concerning the preparation, must be
considered as proper only for the young or middle-aged, in a good
state of health; but among those who are desirous of inoculation are
often found tender, delicate, and weakly women, men of bad stamina,
valetudinarians by constitution, by illness, or intemperance; also
aged persons and children; and for these a very different treatment
is directed; a milder course of medicine, rather of the alterative
than purgative kind, is here preferable; and in many instances, an
indulgence in some light animal food, with a glass or two of wine in
case of lowness, is not only allowable, but necessary to support a
proper degree of strength, especially in advanced age.
Children whose bowels are often tender, and ought not to be ruffled by
strong purges, yet require a mild mercurial, and bear it well; besides
emptying the bowels of crudities, it is a good security against worms
and their effects, which are sometimes of themselves perplexing enough,
and produce very alarming and even fatal disorders.
Indeed the particular state of health of every person entering upon the
preparatory course, should be inquired into and considered. Inattention
to this has, I am satisfied, done great mischief, and particularly
the indiscreet use of mercurials, whereby a salivation has often been
raised, to the risque of impairing good constitutions, and the ruin of
such as were previously weak and infirm. The distinctions and treatment
necessary, will be obvious to those who are acquainted with the animal
œconomy and medical practice.
The time of menstruation has generally been the guide in respect to
the inoculation of women; that the whole of the disease might be over
within the menstrual period. This I commonly observe, when I can
choose my time without any inconvenience, and inoculate soon after
the evacuation ceases; though I have no reason to decline performing
the operation at any time, as I can produce many examples in which no
inconvenience has arisen, nor any difference been observable, when this
circumstance has been disregarded.
Women with child have likewise been inoculated, and done well; yet
some particular emergency should be pleaded in excuse for it in
their situation, as it may be attended with some hazard. I have
not inoculated any woman whom I knew to be pregnant; but some who
concealed their pregnancy have been inoculated by me, who, I fancy,
hoped for an event that did not happen, I mean miscarriages: one of
these had a child born nine weeks after inoculation, at the full time,
with distinct marks of the disease, though the mother had very few
eruptions.
Of INFECTION.
The manner of communicating this distemper by inoculation in this
country, has of late been the following: A thread is drawn through
a ripe pustule, and well moistened with the matter: a piece of this
thread is insinuated into a superficial incision made in one or both
arms, near the part where issues are usually fixed; this thread is
covered with a plaister, and there left for a day or two. This is the
most usual way, though others have been practised by several in the
profession.
At present, very different methods are pursued; two of which, that vary
in some respects, I have frequently practised, and shall describe; but
the following has been so invariably successful, as to induce me to
give it the preference.
The patient to be infected being in the same house, and, if no
objection is made to it, in the same room, with one who has the
disease, a little of the variolous matter is taken from the place of
insertion, if the subject is under inoculation; or a pustule, if in the
natural way, on the point of a lancet, so that both sides of the point
are moistened.
With this lancet an incision is made in that part of the arm where
issues are usually placed, deep enough to pass through the scarf skin,
and just to touch the skin itself, and in length as short as possible,
not more than one eighth of an inch.
The little wound being then stretched open between the finger and thumb
of the operator, the incision is moistened with the matter, by gently
touching it with the flat side of the infested lancet. This operation
is generally performed in both arms, and sometimes in two places in one
arm, a little distance from each other. For as I have not observed any
inconvenience from two or three incisions, I seldom trust to one; that
neither I nor my patient may be under any doubt about the success of
the operation from its being performed in one place only.
I have also tried the following method, with the same success as that
above described, but do not so well approve of it, because I have been
credibly informed that it has sometimes failed in the practice of
others. A lancet being moistened with the variolous fluid in the same
manner as in the other, is gently introduced, in an oblique manner,
between the scarf and true skin, and the finger of the operator is
applied on the point, in order to wipe off the infection from the
lancet, when it is withdrawn. In this method, as well as in the former,
a little blood will sometimes appear, but I neither draw blood with
design, nor do I think it necessary to wipe it off before the matter is
introduced.
In both these ways of inoculating, neither plaister, bandage, or
covering is applied, or in any respect necessary.
These methods of producing the disease never once have failed me;
and experience has sufficiently proved, that there is no danger from
additional infection by the natural disease at the same time. I
therefore make no scruple of having the person to be inoculated, and
the patient from whom the infection is to be taken, in the same room;
nor have ever perceived any ill consequences attending it. But I advise
the inoculated patients (though perhaps there is no necessity for that
precaution) to be afterwards separated from places of infection till
certain signs of success appear, when all restraint is removed, there
being no danger from accumulation.
It seems to be of no consequence whether the infecting matter be taken
from the natural or inoculated small-pox; I have used both, and never
have been able to discover the least difference, either in point of
certainty of infection, the progress, or the event: and therefore I
take the infection from either, as opportunity offers, or at the option
of my patients or their friends.
Nor is it of consequence whether the matter be taken before, or at the
crisis of, the distemper. It is, I believe, generally supposed, that
the small-pox is not infectious till after the matter has acquired a
certain degree of maturity; and in the common method of inoculation,
this is much attended to; and when the operation has failed, it has
commonly been ascribed to the unripeness of the matter.
But it appears very clearly from the present practice of inoculation,
that so soon as any moisture can be taken from the infected part of
an inoculated patient, previous to the appearance of any pustules,
and even previous to the eruptive fever, this moisture is capable of
communicating the small-pox with the utmost certainty. I have taken a
little clear fluid from the elevated pellicle on the incised part, even
so early as the fourth day after the operation, and have at other times
used matter fully digested at the crisis, with equal success. I chuse,
however, in general, to take matter for infection during the fever of
eruption, as I suppose it at that time to have its utmost activity.
In all cases, when I take matter from an inoculated person, it is from
the place where it was inserted; as I am always sure to find infection
there if the disease succeeds, and always of sufficient energy.
It may appear strange that no bandage, dressing, or application
whatsoever, is made use of to the part infected; but that the most
simple incision being made, and moistened with the smallest particle of
the recent fluid matter, the whole is committed to nature. This method
is however perfectly right, because the application of either plaister
or unguent, as is the usual practice, will occasion an inflammation on
some skins, and in all tend to disguise the natural appearance of the
incision, and prevent our forming a proper judgment of the progress
of the infection; which will afterwards appear to be a matter of much
importance.
If neither an inoculated patient is at hand, nor any one in the
neighbourhood has a distinct kind of the natural disease, a thread may
be used as in the common manner, provided the thread be very recently
infected; but I think it ought to be used as soon as possible after
being charged with infecting matter.
The following method of introducing the disease has likewise been
found effectual; but I have never practised it myself. Dip the point
of a lancet in variolous matter; let it be held in the air till it is
dry; after which it may be closed and kept in the common case without
any further care; and with this prepared lancet raise the scarf skin
obliquely, and keep the lancet a little time in motion between the two
skins, that part of the matter may be mixed with the animal juices;
then withdraw the lancet, and leave the incision uncovered as before.