matter is capable of producing full and decisive effects on the
constitution, to that wherein its specific properties are
entirely lost, it may reasonably be supposed that it is capable
of undergoing a variety of intermediate changes. The following
singular occurrences in ten cases of inoculation, obligingly
communicated to me by Mr. Trye, Senior Surgeon to the Infirmary
at Glocester, seem to indicate that the variolous matter,
previously to its being taken from the patient for the intended
purpose, was beginning to part with some of its original
properties, or, in other words, that it had suffered a partial
decomposition. Mr. Trye says: "I inoculated ten children with
matter taken at one time and from the same subject. I observed no
peculiarity in any of them previously to their inoculation, nor
did any thing remarkable appear in their arms till after the
decline of the disease. Two infants of three months old had
erysipelas about the incisions, in one of them extending from the
shoulders to the fingers' ends. Another infant had abscesses in
the cellular substance in the neighbourhood of the incisions, and
five or six of the rest had axillary abscesses. The matter was
taken from the distinct smallpox late in its progress, and when
some pustules had been dried. It was received upon glass and
slowly dried by the fire. All the children had pustules which
maturated, so that I suppose them all secure from future
infection; at least, as secure as any others whom I have ever
inoculated. My practice never afforded a sore arm before."
In regard to my former observation on the improper and dangerous
mode of preserving variolous matter, I shall here remark that it
seems not to have been clearly understood. Finding that it has
been confounded with the more eligible modes of preservation, I
will explain myself further. When the matter is taken from a fit
pustule and properly prepared for preservation, it may certainly
be kept without losing its specific properties a great length of
time; for instance, when it is previously dried in the open air
on some compact body, as a quill or a piece of glass, and
afterwards secured in a small vial. [Footnote: Thus prepared, the
cow-pox virus was found perfectly active, and possessing all its
specific properties, at the end of three months.] But when kept
several days in a state of moisture, and during that time exposed
to a warm temperature, I do not think it can be relied upon as
capable of giving a perfect disease, although, as I have before
observed, the progress of the symptoms arising from the action of
the imperfect matter bear so strong a resemblance to the smallpox
when excited completely.
Thirdly. That the first formed virus, or what constitutes the
true cow-pox pustule, invariably possesses the power I have
ascribed to it, namely, that of affecting the constitution with a
specific disease, is a truth that no subsequent occurrence has
yet led me to doubt. But as I am now endeavouring to guard the
public as much as possible against erroneous conclusions, I shall
observe that when this pustule has degenerated into an ulcer (to
which state it is often disposed to pass unless timely checked),
I suspect that matter possessing very different properties may
sooner or later be produced; and although it may have passed that
stage wherein the specific properties of the matter secreted are
no longer present in it, yet when applied to a sore (as in the
casual way) it might dispose that sore to ulcerate, and from its
irritation the system would probably become affected; and thus,
by assuming some of its strongest characters, it would imitate
the genuine cow-pox.
From the preceding observations on the matter of smallpox when
decomposed it must, I conceive, be admitted that cow-pox matter
in the state now described may produce a disease, the effects of
which may be felt both locally and generally, yet that the
disease thus induced may not be effectual in obviating the future
effects of variolous contagion. In the case of Mary Miller,
related by Mr. Kite in the volume above alluded to, it appears
that the inflammation and suppuration of the inoculated arm were
more than usually severe, although the system underwent no
specific change from the action of the virus; which appears from
the patient's sickening seven weeks afterwards with the natural
smallpox, which went through its course. Some of the cases
communicated by Mr. Earle tend further to confirm this fact, as
the matter there manifestly produced ulceration on the inoculated
part to a considerable extent.
Fourthly. Whether the cow-pox is a spontaneous disease in the
cow, or is to be attributed to matter conveyed to the animal, as
I have conceived, from the horse, is a question which, though I
shall not attempt now fully to discuss, yet I shall digress so
far as to adduce some further observations, and to give my
reasons more at large for taking up an opinion that to some had
appeared fanciful. The aggregate of these observations, though
not amounting to positive proof, forms presumptive evidence of so
forcible a kind that I imagine it might, on any other person,
have made the same impression it did on me, without fixing the
imputation of credulity.
First: I conceived this was the source, from observing that where
the cow-pox had appeared among the dairies here (unless it could
be traced to the introduction of an infected cow or servant) it
had been preceded at the farm by a horse diseased in the manner
already described, which horse had been attended by some of the
milkers.
Secondly: From its being a popular opinion throughout this great
dairy country, and from its being insisted on by those who here
attend sick cattle.
Thirdly: From the total absence of the disease in Ireland and
Scotland, where the men-servants are not employed in the dairies.
[Footnote: This information was communicated to me from the first
authority.]
Fourthly: From having observed that morbid matter generated by
the horse frequently communicates, in a casual way, a disease to
the human subject so like the cow-pox that, in many cases, it
would be difficult to make the distinction between one and the
other. [Footnote: The sound skin does not appear to be
susceptible of this virus when inserted into it, but, when
previously diseased from little accidents, its effects are often
conspicuous.]
Fifthly: From being induced to suppose, from experiments, that
some of those who had been thus affected from the horse resisted
the smallpox.
Sixthly: From the progress and general appearance of the pustule
on the arm of the boy whom I inoculated with matter taken from
the hand of a man infected by a horse; and from the similarity to
the cow-pox of general constitutional symptoms which followed.
[Footnote: This case (on which I laid no inconsiderable stress in
my late treatise, as presumptive evidence of the fact adduced)
seems to have been either mistaken or overlooked by those who
have commented upon it. (See Case XVIII, p. 36.) The boy,
unfortunately, died of a fever at a parish workhouse before I had
an opportunity of observing what effects would have been produced
by the matter of smallpox.]
I fear it would be trespassing too far to adduce the general
testimony of our farmers in support of this opinion; yet I beg
leave to introduce an extract of a letter on this subject from
the Rev. Mr. Moore, of Chalford Hill, in this county:
"In the month of November, 1797, my horse had diseased heels,
which was certainly what is termed the grease; and at a short
subsequent period my cow was also affected with what a
neighbouring farmer (who was conversant with the complaints of
cattle) pronounced to be the cow-pox, which he at the same time
observed my servant would be infected with: and this proved to be
the case; for he had eruptions on his hands, face, and many,
parts of the body, the pustules appearing large, and not much
like the smallpox, for which he had been inoculated a year and a
half before, and had then a very heavy burthen. The pustules on
the face might arise from contact with his hands, as he had a
habit of rubbing his forehead, where the sores were the largest
and the thickest.
"The boy associated with the farmer's sons during the continuance
of the disease, neither of whom had had the smallpox, but they
felt no ill effects whatever. He was not much indisposed, as the
disease did not prevent him from following his occupations as
usual. No other person attended the horse or milked the cow but
the lad above mentioned. I am firmly of opinion that the disease
in the heels of the horse, which was a virulent grease, was the
origin of the servant's and the cow's malady."
But to return to the more immediate object of this proposition.
From the similarity of symptoms, both constitutional and local,
between the cow-pox and the disease received from morbid matter
generated by a horse, the common people in this neighbourhood,
when infected with this disease, through a strange perversion of
terms, frequently call it the cow-pox. Let us suppose, then, such
a malady to appear among some of the servants at a farm, and at
the same time that the cow-pox were to break out among the
cattle; and let us suppose, too, that some of the servants were
infected in this way, and that others received the infection from
the cows. It would be recorded at the farm, and among the
servants themselves wherever they might afterwards be dispersed,
that they had all had the cow-pox. But it is clear that an
individual thus infected from the horse would neither be for a
certainty secure himself, nor would he impart security to others
were they inoculated by virus thus generated. He still would be
in danger of taking the smallpox. Yet were this to happen before
the nature of the cowpox be more maturely considered by the
public my evidence on the subject might be depreciated unjustly.
For an exemplification of what is here advanced relative to the
nature of the infection when received directly from the horse see
Inquiry into the Causes and Effects of the Variolae Vaccinae, pp.
27, 28, 29, 30, and p. 35; and by way of further example, I beg
leave to subjoin the following intelligence received from Mr.
Fewster, Surgeon, of Thornbury, in this county, a gentleman
perfectly well acquainted with the appearances of the cow-pox on
the human subject:
"William Morris, aged thirty-two, servant to Mr. Cox of
Almondsbury, in this county, applied to me the 2d of April, 1798.
He told me that, four days before, be found a stiffness and
swelling in both his hands, which were so painful it was with
difficulty he continued his work; that he had been seized with
pain in his head, small of the back, and limbs, and with frequent
chilly fits succeeded by fever. On examination I found him still
affected with these symptoms, and that there was a great
prostration of strength. Many parts of his hands on the inside
were chapped, and on the middle joint of the thumb of the right
hand there was a small phagedenic ulcer, about the size of a
large pea, discharging an ichorous fluid. On the middle finger of
the same hand there was another ulcer of a similar kind. These
sores were of a CIRCULAR form, and he described their first
appearance as being somewhat like blisters arising from a burn.
He complained of excessive pain, which extended up his arm into
the axilla. These symptoms and appearances of the sores were so
exactly like the cow-pox that I pronounced he had taken the
distemper from milking cows. He assured me he had not milked a
cow for more than half a year, and that his master's cows had
nothing the matter with them. I then asked him if his master had
a GREASY horse, which he answered in the affirmative, and further
said that he had constantly dressed him twice a day for the
[Footnote: HC--Vol.88] last three weeks or more, and remarked
that the smell of his hands was much like that of the horses's
heels. On the 5th of April I again saw him, and found him still
complaining of pain in both hands, nor were his febrile symptoms
at all relieved. The ulcers had now spread to the size of a
seven-shilling gold coin, and another ulcer, which I had not
noticed before, appeared on the first joint of the forefinger of
the left hand, equally painful with that on the right. I ordered
him to bathe his hands in warm bran and water, applied
escharotics to the ulcers, and wrapped his hands up in a soft
cataplasm. The next day he was much relieved, and in something
more than a fortnight got well. He lost his nails from the thumb
and fingers that were ulcerated."
The sudden disappearance of the symptoms in this case after the
application of the escharotics to the sores is worthy of
observation; it seems to show that they were kept up by the
irritation of the ulcers.
The general symptoms which I have already described of the cow-
pox, when communicated in a casual way to any great extent, will,
I am convinced, from the many cases I have seen, be found
accurate; but from the very slight indisposition which ensues in
cases of inoculation, where the pustule, after affecting the
constitution, quickly runs into a scab spontaneously, or is
artificially suppressed by some proper application, I am induced
to believe that the violence of the symptoms may be ascribed to
the inflammation and irritation of the ulcers (when ulceration
takes place to any extent, as in the casual cow-pox), and that
the constitutional symptoms which appear during the presence of
the sore, while it assumes the character of a pustule only, are
felt but in a very trifling degree. This mild affection of the
system happens when the disease makes but a slight local
impression on those who have been accidentally infected by cows;
and, as far as I have seen, it has uniformly happened among those
who have been inoculated, when a pustule only and no great degree
of inflammation or any ulceration has taken place from the
inoculation. The following cases will strengthen this opinion.
The cow-pox appeared at a farm in the village of Stonehouse, in
this county, about Michaelmas last, and continued gradually to
pass from one cow to another till the end of November, On the
twenty-sixth of that month some ichorous matter was taken from a
cow and dried upon a quill. On the 2d of December some of it was
inserted into a scratch, made so superficial that no blood
appeared, on the arms of Susan Phipps, a child seven years old.
The common inflammatory appearances took place in consequence,
and advanced till the fifth day, when they had so much subsided
that I did not conceive any thing further would ensue.
6th: Appearances stationary.
7th: The inflammation began to advance.
8th: A vesication, perceptible on the edges, forming, as in the
inoculated smallpox, an appearance not unlike a grain of wheat,
with the cleft, or indentation in the centre.
9th: Pain in the axilla.
10th: A little headache; pulse, 110; tongue not discoloured;
countenance in health.
11th, 12th: No perceptible illness; pulse about 100.
13th: The pustule was now surrounded by an efflorescence,
interspersed with very minute confluent pustules to the extent of
about an inch. Some of these pustules advanced in size and
maturated. So exact was the resemblance of the arm at this stage
to the general appearance of the inoculated smallpox that Mr. D.,
a neighbouring surgeon, who took some matter from it, and who had
never seen the cow-pox before, declared he could not perceive any
difference. [Footnote: That the cow-pox was a supposed guardian
of the constitution from the action of the smallpox has been a
prevalent idea for a long time past; but the similarity in the
constitutional effects between one disease and the other could
never have been so accurately observed had not the inoculation of
the cow-pox placed it in a new and stronger point of view. This
practice, too, has shewn us, what before lay concealed, the rise
and progress of the pustule formed by the insertion of the virus,
which places in a most conspicuous light its striking resemblance
to the pustule formed from the inoculated smallpox.] The child's
arm now shewed a disposition to scab, and remained nearly
stationary for two or three days, when it began to run into an
ulcerous state, and THEN commenced a febrile indisposition
accompanied with an increase of axillary tumour. The ulcer
continued spreading near a week, during which time the child
continued ill, when it increased to a size nearly as large as a
shilling. It began now to discharge pus; granulations sprang up,
and it healed. This child had before been of a remarkably sickly
constitution, but is now in very high health.
Mary Hearn, twelve years of age, was inoculated with matter taken
from the arm of Susan Phipps.
6th day: A pustule beginning to appear, slight pain in the
axilla.
7th: A distinct vesicle formed.
8th: The vesicle increasing; edges very red; no deviation in its
appearance at this time from the inoculated smallpox.
9th: No indisposition; pustule advancing.
10th: The patient felt this evening a slight febrile attack.
11th: Free from indisposition.
12th, 13th: The same.
14th: An efflorescence of a faint red colour extending several
inches round the arm. The pustule, beginning to shew a
disposition to spread, was dressed with an ointment composed of
hydrarg. nit. rub. and ung. cerce. The efflorescence itself was
covered with a plaster of ung. hydr. fort. In six hours it was
examined, when it was found that the efflorescence had totally
disappeared.
The application of the ointment with the hydr. nit. rub. was made
use of for three days, when, the state of the pustule remaining
stationary, it was exchanged for the ung. hydr. nit. This
appeared to have a more active effect than the former, and in two
or three days the virus seemed to be subdued, when a simple
dressing was made use of; but the sore again shewing a
disposition to inflame, the ung. hydr. nit. was again applied,
and soon answered the intended purpose effectually. The girl,
after the tenth day, when, as has been observed, she became a
little ill, shewed not the least symptom of indisposition. She
was afterwards exposed to the action of variolous; matter, and
completely resisted it. Susan Phipps also went through a similar
trial. Conceiving these cases to be important, I have given them
in detail: first, to urge the precaution of using such means as
may stop the progress of the pustule; and, secondly, to point out
(what appears to be the fact) that the most material
indisposition, or at least that which is felt most sensibly, DOES
NOT ARISE PRIMARILY FROM THE FIRST ACTION OF THE VIRUS ON THE
CONSTITUTION, BUT THAT IT OFTEN COMES ON, IF THE PUSTULE IS LEFT
TO CHANCE, AS A SECONDARY DISEASE. This leads me to conjecture,
what experiment must finally determine, that they who have had
the smallpox are not afterwards susceptible of the primary action
of the cow-pox virus; for seeing that the simple virus itself,
when it has not passed beyond the boundary of a vesicle, excites
in the system so little commotion, is it not probable the
trifling illness, thus induced may be lost in that which so
quickly, and oftentimes so severely, follows in the casual cow-
pox from the presence of corroding ulcers? This consideration
induces me to suppose that I may have been mistaken in my former
observation on this subject.
In this respect, as well as many others, a parallel may be drawn
between this disease and the smallpox. In the latter, the patient
first feels the effect of what is called the absorption of the
virus. The symptoms then often nearly retire, when a fresh attack
commences, different from the first, and the illness keeps pace
with the progress of the pustules through their different stages
of maturation, ulceration, etc. Although the application I have
mentioned in the case of Mary Hearn proved sufficient to check
the progress of ulceration and prevent any secondary symptoms,
yet, after the pustule has duly exerted its influence, I should
prefer the destroying it quickly and effectually to any other
mode. The term caustic to a tender ear (and I conceive none feel
more interested in this inquiry than the anxious guardians of a
nursery) may sound harsh and unpleasing, but every solicitude
that may arise on this account will no longer exist when it is
understood that the pustule, in a state fit to be acted upon, is
then quite superficial, and that it does not occupy the space of
a silver penny. [Footnote: I mention escharotics for stopping the
progress of the pustule because I am acquainted with their
efficacy; probably more simple means might answer the purpose
quite as well, such as might be found among the mineral and
vegetable astringents.]
As a proof of the efficacy of this practice, even before the
virus has fully exerted itself on the system, I shall lay before
my reader the following history:
By a reference to the treatise on the Variolae Vaccinae it will
be seen that, in the month of April, 1798, four children were
inoculated with the matter of cow-pox, and that in two of these
cases the virus on the arm was destroyed soon after it had
produced a perceptible sickening. Mary James, aged seven years,
one of the children alluded to, was inoculated in the month of
December following with fresh variolous matter, and at the same
time was exposed to the effluvia of a patient affected with the
smallpox. The appearance and progress of the infected arm was, in
every respect similar to that which we generally observe when
variolous matter has been inserted into the skin of a person who
has not previously undergone either the cow-pox or the smallpox.
On the eighth day, conceiving there was infection in it, she was
removed from her residence among those who had not had the
smallpox. I was now anxiously waiting the result, conceiving,
from the state of the girl's arm, she would fall sick about this
time. On visiting her on the evening of the following day (the
ninth) all I could learn from the woman who attended her was that
she felt somewhat hotter than usual during the night, but was not
restless; and that in the morning there was the faint appearance
of a rash about her wrists. This went off in a few hours, and was
not at all perceptible to me on my visit in the evening. Not a
single eruption appeared, the skin having been repeatedly and
carefully examined. The inoculated arm continued to make the
usual progress to the end, through all the stages of
inflammation, maturation, and scabbing.
On the eighth day matter was taken from the arm of this girl
(Mary James) and inserted into the arms of her mother and brother
(neither of whom had had either the smallpox or the cow-pox), the
former about fifty years of age, the latter six.
On the eighth day after the insertion the boy felt indisposed,
and continued unwell two days, when a measles-like rash appeared
on his hands and wrists, and was thinly scattered over his arms.
The day following his body was marbled over with an appearance
somewhat similar, but he did not complain, nor did he appear
indisposed. A few pustules now appeared, the greater part of
which went away without maturating.
On the ninth day the mother began to complain. She was a little
chilly and had a headache for two days, but NO PUSTULE APPEARED
on the skin, nor had she any appearance of a rash.
The family was attended by an elderly woman as a nurse, who in
her infancy had been exposed to the contagion of the smallpox,
but had resisted it. This woman was now infected, but had the
disease in the slightest manner, a very few eruptions appearing,
two or three of which only maturated.
From a solitary instance like that adduced of Mary James, whose
constitution appears to have resisted the action of the variolous
virus, after the influence of the cow-pox virus had been so soon
arrested in its progress, no positive conclusion can be fairly
drawn; nor from the history of the three other patients who were
subsequently infected, but, nevertheless, the facts collectively
may be deemed interesting.
That one mild variety of the smallpox has appeared I have already
plainly shewn; [Footnote: See Inquiry into the Causes and Effects
of the Variolae Vaccinae, p. 54 (of original article)], and by
the means now mentioned we probably have it in our power to
produce at will another.
At the time when the pustule was destroyed in the arm of Mary
James I was informed she had been indisposed about twelve hours;
but I am now assured by those who were with her that the space of
time was much less. Be that as it may, in cases of cow-pox
inoculation I would not recommend any application to subdue the
action of the pustule until convincing proofs had appeared of the
patient's having felt its effects at least twelve hours. No harm,
indeed, could ensue were a longer period to elapse before the
application was made use of. In short, it should be suffered to
have as full an effect as it could, consistently with the state
of the arm.
As the cases of inoculation multiply, I am more and more
convinced of the extreme mildness of the symptoms arising merely
from the primary action of the virus on the constitution, and
that those symptoms which, as in the accidental cow-pox, affect
the patient with severity, are entirely secondary, excited by the
irritating processes of inflammation and ulceration; and it
appears to me that this singular virus possesses an irritating
quality of a peculiar kind, but as a single cow-pox pustule is
all that is necessary to render the variolous virus ineffectual,
and as we possess the means of allaying the irritation, should
any arise, it becomes of little or no consequence.
It appears then, as far as an inference can be drawn from the
present progress of cow-pox inoculation, that it is an accidental
circumstance only which can render this a violent disease, and a
circumstance of that nature which, fortunately, it is in the
power of almost every one to avoid. I allude to the communication
of the disease from cows. In this case, should the hands of the
milker be affected with little accidental sores to any extent,
every sore would become the nidus of infection and feel the
influence of the virus; and the degree of violence in the
constitutional symptoms would be in proportion to the number and
to the state of these local affections. Hence it follows that a
person, either by accident or design, might be so filled with
these wounds from contact with the virus that the constitution
might sink under the pressure.
Seeing that we possess the means of rendering the action of the
sores mild, which, when left to chance, are capable of producing
violent effects; and seeing, too, that these sores bear a
resemblance to the smallpox, especially the confluent, should it
not encourage the hope that some topical application might be
used with advantage to counteract the fatal tendency of that
disease, when it appears in this terrific form? At what stage or
stages of the disease this may be done with the most promising
expectation of success I will not pretend now to determine. I
only throw out this idea as the basis of further reasoning and
experiment.
I have often been foiled in my endeavours to communicate the cow-
pox by inoculation. An inflammation will sometimes succeed the
scratch or puncture, and in a few days disappear without
producing any further effect. Sometimes it will even produce an
ichorous fluid, and yet the system will not be affected. The same
thing we know happens with the smallpox virus.
Four or five servants were inoculated at a farm contiguous to
this place, last summer, with matter just taken from an infected
cow. A little inflammation appeared on all their arms, but died
away without producing a pustule; yet all these servants caught
the disease within a month afterwards from milking the infected
cows, and some of them had it severely. At present no other mode
than that commonly practiced for inoculating the smallpox has
been used for giving the cow-pox; but it is probable this might
be varied with advantage. We should imitate the casual
communication more clearly were we first, by making the smallest
superficial incision or puncture on the skin, to produce a little
scab, and then, removing it, to touch the abraded part with the
virus. A small portion of a thread imbrued in the virus (as in
the old method of inoculating the smallpox) and laid upon the
slightly incised skin might probably prove a successful way of
giving the disease; or the cutis might be exposed in a minute
point by an atom of blistering plaster, and the virus brought in
contact with it. In the cases just alluded to, where I did not
succeed in giving the disease constitutionally, the experiment
was made with matter taken in a purulent state from a pustule on
the nipple of a cow.
Is PURE PUS, though contained in a smallpox pustule, ever capable
of producing the smallpox perfectly? I suspect it is not. Let us
consider that it is always preceded by the limpid fluid, which,
in constitutions susceptible of variolous contagion, is always
infectious; and though, on opening a pustule, its contents may
appear perfectly purulent, yet a given quantity of the limpid
fluid may, at the same time, be blended with it, though it would
be imperceptible to the only test of our senses, the eye. The
presence, then, of this fluid, or its mechanical diffusion
through pus, may at all times render active what is apparently
MERE PUS, while its total absence (as in stale pustules) may be
attended with the imperfect effects we have seen.
It would be digressing too widely to go far into the doctrine of
secretion, but as it will not be quite extraneous, I shall just
observe that I consider both the pus and the limpid fluid of the
pustule as secretions, but that the organs established by nature
to perform the office of secreting these fluids may differ
essentially in their mechanical structure. What but a difference
in the organization of glandular bodies constitutes the
difference in the qualities of the fluids secreted? From some
peculiar derangement in the structure or, in other words, some
deviation in the natural action of a gland destined to create a
mild, innoxious fluid, a poison of the most deadly nature may be
created; for example: That gland, which in its sound state
secretes pure saliva, may, from being thrown into diseased
action, produce a poison of the most destructive quality. Nature
appears to have no more difficulty in forming minute glands among
the vascular parts of the body than she has in forming blood
vessels, and millions of these can be called into existence, when
inflammation is excited, in a few hours. [Footnote: Mr. Home, in
his excellent dissertation on pus and mucus, justifies this
assertion.]
In the present early stage of the inquiry (for early it certainly
must be deemed), before we know for an absolute certainty how
soon the virus of the cow-pox may suffer a change in its specific
properties, after it has quitted the limpid state it possesses
when farming a pustule, it would be prudent for those who have
been inoculated with it to submit to variolous inoculation. No
injury or inconvenience can accrue from this; and were the same
method practiced among those who, from inoculation, have felt the
smallpox in an unsatisfactory manner at any period of their
lives, it might appear that I had not been too officious in
offering a cautionary, hint in recommending a second inoculation
with matter in its most perfect state.
And here let me suppose, for argument's sake (not from
conviction), that one person in an hundred after having had the
cow-pox should be found susceptible of the smallpox, would this
invalidate the utility of the practice? For, waiving all other
considerations, who will deny that the inoculated smallpox,
although abstractedly it may be considered as harmless, does not
involve in itself something that in numberless instances proves
baneful to the human frame.
That in delicate constitutions it sometimes excites scrofula is a
fact that must generally be subscribed to, as it is so obvious to
common observation. This consideration is important.
As the effects of the smallpox inoculation on those who have had
the cow-pox will be watched with the most scrupulous eye by those
who prosecute this inquiry, it may be proper to bring to their
recollection some facts relative to the smallpox, which I must
consider here as of consequence, but which hitherto seem not to
have made a due impression.
It should be remembered that the constitution cannot, by previous
infection, be rendered totally unsusceptible of the variolous
poison; neither the casual nor the inoculated smallpox, whether
it produces the disease in a mild or in a violent way, can
perfectly extinguish the susceptibility. The skin, we know, is
ever ready to exhibit, though often in a very limited degree, the
effects of the poison when inserted there; and how frequently do
we see, among nurses, when much exposed to the contagion,
eruptions, and these sometimes preceded by sensible illness! yet
should any thing like an eruption appear, or the smallest degree
of indisposition, upon the insertion of the variolous matter on
those who have gone through the cow-pox, my assertions respecting
the peculiarities of the disease might be unjustly discredited.
I know a gentleman who, many years ago, was inoculated for the
smallpox, but having no pustules, or scarcely any constitutional
affection that was perceptible, he was dissatisfied, and has
since been repeatedly inoculated. A vesicle has always been
produced in the arm in consequence, with axillary swelling and a
slight indisposition; this is by no means a rare occurrence. It
is probable that fluid thus excited upon the skin would always
produce the smallpox.
On the arm of a person who had gone through the cow-pox many
years before I once produced a vesication by the insertion of
variolous matter, and, with a little of the fluid, inoculated a
young woman who had a mild, but very efficacious, smallpox in
consequence, although no constitutional effect was produced on
the patient from whom the matter was taken. The following
communication from Mr. Fewster affords a still clearer
elucidation of this fact. Mr. Fewster says: "On the 3d of April,
1797, I inoculated Master H--, aged fourteen months, for the
smallpox. At the usual time he sickened, had a plentiful
eruption, particularly on his face, and got well. His nursemaid,
aged twenty-four, had many years before gone through the
smallpox, in the natural way, which was evident from her being
much pitted with it. She had used the child to sleep on her left
arm, with her left cheek in contact with his face, and during his
inoculation he had mostly slept in that manner. About a week
after the child got well she (the nurse) desired me to look at
her face, which she said was very painful. There was a plentiful
eruption on the left cheek, BUT NOT ON ANY OTHER PART OF THE
BODY, which went on to maturation.
"On enquiry I found that three days before the appearance of the
eruption she was taken with slight chilly fits, pain in her head
and limbs, and some fever. On the appearance of the eruption
these pains went off, and now, the second day of the eruption,
she complains of a little sore throat. Whether the above symptoms
are the effects of the smallpox or a recent cold I do not know.
On the fifth day of the eruption I charged a lancet from two of
the pustules, and on the next day I inoculated two children, one
two years, the other four months old, with the matter. At the
same time I inoculated the mother and eldest sister with
variolous matter taken from Master H--. On the fifth day of their
inoculation ALL their arms were inflamed alike; and on the eighth
day the eldest of those inoculated from the nurse sickened, and
the youngest on the eleventh. They had both a plentiful eruption,
from which I inoculated several others, who had the disease very
favourably. The mother and the other child sickened about the
same time, and likewise had a plentiful eruption.
"Soon after, a man in the village sickened with the smallpox and
had a confluent kind. To be convinced that the children had had
the disease effectually I took them to his house and inoculated
them in both arms with matter taken from him, but without
effect."
These are not brought forward as uncommon occurrences, but as
exemplifications of the human system's susceptibility of the
variolous contagion, although it has been previously sensible of
its action.
Happy is it for mankind that the appearance of the small-pox a
second time on the same person, beyond a trivial extent, is so
extremely rare that it is looked upon as a phaenomenon! Indeed,
since the publication of Dr. Heberden's paper on the Varicellae,
or chicken-pox, the idea of such an occurrence, in deference to
authority so truly respectable, has been generally relinquished.
This I conceive has been without just reason; for after we have
seen, among many others, so strong a case as that recorded by Mr.
Edward Withers, Surgeon, of Newbury, Berks, in the fourth volume
of the Memoirs of the Medical Society of London (from which I
take the following extracts), no one, I think, will again doubt
the fact.
"Mr. Richard Langford, a farmer of West Shefford, in this county
(Berks), about fifty years of age, when about a month old had the
smallpox at a time when three others of the family had the same
disease, one of whom, a servant man, died of it. Mr. Langford's
countenance was strongly indicative of the malignity of the
distemper, his face being so remarkably pitted and seamed as to
attract the notice of all who saw him, so that no one could
entertain a doubt of his having had that disease in a most
inveterate manner." Mr. Withers proceeds to state that Mr.
Langford was seized a second time, had a bad confluent smallpox,
and died on the twenty-first day from the seizure; and that four
of the family, as also a sister of the patient's, to whom the
disease was conveyed by her son's visiting his uncle, falling
down with the smallpox, fully satisfied the country with regard
to the nature of the disease, which nothing short of this would
have done; the sister died.
"This case was thought so extraordinary a one as to induce the
rector of the parish to record the particulars in the parish
register."
It is singular that in most cases of this kind the disease in the
first instance has been confluent; so that the extent of the
ulceration on the skin (as in the cow-pox) is not the process in
nature which affords security to the constitution.
As the subject of the smallpox is so interwoven with that which
is the more immediate object of my present concern, it must plead
my excuse for so often introducing it. At present it must be
considered is a distemper not well understood. The inquiry I have
instituted into the nature of the cow-pox will probably promote
its more perfect investigation.
The inquiry of Dr. Pearson into the history of the cow-pox having
produced so great a number of attestations in favour of my
assertion that it proves a protection to the human body from the
smallpox, I have not been assiduous in seeking for more; but as
some of my friends have been so good as to communicate the
following, I shall conclude these observations with their
insertion.
Extract of a letter from Mr. Drake, Surgeon, at Stroud, in this
county, and late Surgeon to the North Gloucester Regiment of
Militia:
"In the spring of the year 1796 I inoculated men, women, and
children to the amount of about seventy. Many of the men did not
receive the infection, although inoculated at least three times
and kept in the same room with those who actually underwent the
disease during the whole time occupied by them in passing through
it. Being anxious they should, in future, be secure against it, I
was very particular in my inquiries to find out whether they ever
had previously had it, or at any time been in the neighbourhood
of people labouring under it. But, after all, the only
satisfactory information I could obtain was that they had had the
cow-pox. As I was then ignorant of such a disease affecting the
human subject, I flattered myself what they imagined to be the
cow-pox was in reality the smallpox in a very slight degree. I
mentioned the circumstance in the presence of the officers, at
the time expressing my doubts if it were not smallpox, and was
not a little surprised when I was told by the Colonel that he had
frequently heard you mention the cow-pox as a disease endemial to
Gloucestershire, and that if a person were ever affected by it,
you supposed him afterwards secure from the smallpox. This
excited my curiosity, and when I visited Gloucestershire I was
very inquisitive concerning the subject, and from the information
I have since received, both from your publication and from
conversation with medical men of the greatest accuracy in their
observations, I am fully convinced that what the men supposed to
be cow-pox was actually so, and I can safely affirm that they
effectually resisted the smallpox."
Mr. Fry, Surgeon, at Dursley in this county, favours me with the
following communication:
"During the spring of the year 1797 I inoculated fourteen hundred
and seventy-five patients, of all ages, from a fortnight old to
seventy years; amongst whom there were many who had previously
gone through the cow-pox. The exact number I cannot state; but if
I say there were nearly thirty, I am certainly within the number.
There was not a single instance of the variolous matter producing
any constitutional effect on these people, nor any greater degree
of local inflammation than it would have done in the arm of a
person who had before gone through the smallpox, notwithstanding
it was invariably inserted four, five, and sometimes six
different times, to satisfy the minds of the patients. In the
common course of inoculation previous to the general one scarcely
a year passed without my meeting with one or two instances of
persons who had gone through the cow-pox, resisting the action of
the variolous contagion. I may fairly say that the number of
people I have seen inoculated with the smallpox who, at former
periods, had gone through the cow-pox, are not less than forty;
and in no one instance have I known a patient receive the
smallpox, notwithstanding they invariably continued to associate
with other inoculated patients during the progress of the
disease, and many of them purposely exposed themselves to the
contagion of the natural smallpox; whence I am fully convinced
that a person who had fairly had the cow-pox is no longer capable
of being acted upon by the variolous matter.
"I also inoculated a very considerable number of those who had
had a disease which ran through the neighbourhood a few years
ago, and was called by the common people the swine-pox, not one
of whom received the smallpox. [Footnote: This was that mild
variety of the smallpox which I have noticed in the late Treatise
on the Cow-Pox (p. 233).]
"There were about half a dozen instances of people who never had
either the cow-or swine-pox, yet did not receive the smallpox,
the system not being in the least deranged, or the arms inflamed,
although they were repeatedly inoculated, and associated with
others who were labouring under the disease; one of them was the
son of a farrier."
Mr. Tierny, Assistant Surgeon of the South Gloucester Regiment of
Militia, has obliged me with the following information:
"That in the summer of the year of 1798 he inoculated a great
number of the men belonging to the regiment, and that among them
he found eleven who, from having lived in dairies, had gone
through the cow-pox. That all of them resisted the smallpox
except one, but that on making the most rigid and scrupulous
enquiry at the farm in Gloucestershire, where the man said he
lived when he had the disease, and among those with whom, at the
same time, he declared he had associated, and particularly of a
person in the parish, whom he said had dressed his fingers, it
most clearly appeared that he aimed at an imposition, and that he
never had been affected with the cow-pox." [Footnote: The public
cannot be too much upon their guard respecting persons of this
description.] Mr. Tierny remarks that the arms of many who were
inoculated after having had the cow-pox inflamed very quickly,
and that in several a little ichorous fluid was formed.
Mr. Cline, who in July last was so obliging at my request as to
try the efficacy of the cow-pox virus, was kind enough to give me
a letter on the result of it, from which the following is an
extract:
"My DEAR SIR:
"The cow-pox experiment has succeeded admirably. The child
sickened on the seventh day, and the fever, which was moderate,
subsided on the eleventh. The inflammation arising from the
insertion of the virus extended to about four inches in diameter,
and then gradually subsided, without having been attended with
pain or other inconvenience. There were no eruptions.
"I have since inoculated him with smallpox matter in three
places, which were slightly inflamed on the third day, and then
subsided.
"Dr. Lister, who was formerly physician to the Smallpox Hospital,
attended the child with me, and he is convinced that it is not
possible to give him the smallpox. I think the substituting the
cow-pox poison for the smallpox promises to be one of the
greatest improvements that has ever been made in medicine; and
the more I think on the subject, the more I am impressed with its
importance.
"With great esteem
"I am, etc., "HENRY CLINE.
"Lincoln's Inn Fields, August 2, 1798."
From communications, with which I have been favoured from Dr.
Pearson, who has occasionally reported to me the result of his
private practice with the vaccine virus in London, and from Dr.
Woodville, who also has favoured me with an account of his more
extensive inoculation with the same virus at the Smallpox
Hospital, it appears that many of their patients have been
affected with eruptions, and that these eruptions have maturated
in a manner very similar to the variolous. The matter they made
use of was taken in the first instance from a cow belonging to
one of the great milk farms in London. Having never seen
maturated pustules produced either in my own practice among those
who were casually infected by cows, or those to whom the disease
had been communicated by inoculation, I was desirous of seeing
the effect of the matter generated in London, on subjects living
in the country. A thread imbrued in some of this matter was sent
to me, and with it two children were inoculated, whose cases I
shall transcribe from my notes.
Stephen Jenner, three years and a half old.
3d day: The arm shewed a proper and decisive inflammation.
6th: A vesicle arising.
7th: The pustule of a cherry colour.
8th: Increasing in elevation. A few spots now appear on each arm
near the insertion of the inferior tendons of the biceps muscles.
They are very small and of a vivid red colour. The pulse natural;
tongue of its natural hue; no loss of appetite or any symptom of
indisposition.
9th: The inoculated pustule on the arm this evening began to
inflame, and gave the child uneasiness; he cried and pointed to
the seat of it, and was immediately afterwards affected with
febrile symptoms. At the expiration of two hours after the
seizure a plaster of ung. hydrarg. fort, was applied, and its
effect was very quickly perceptible, for in ten minutes he
resumed his usual looks and playfulness. On examining the arm
about three hours after the application of the plaster its
effects in subduing the inflammation were very manifest.
10th: The spots on the arms have disappeared, but there are three
visible in the face.
11th: Two spots on the face are gone; the other barely
perceptible.
13th: The pustule delineated in the second plate in the Treatise
on the Variolae Vaccinae is a correct representation of that on
the child's arm as it appears at this time.
14th: Two fresh spots appear on the face. The pustule on the arm
nearly converted into a scab. As long as any fluid remained in it
it was limpid.
James Hill, four years old, was inoculated on the same day, and
with part of the same matter which infected Stephen Jenner. It
did not appear to have taken effect till the fifth day.
7th: A perceptible vesicle: this evening the patient became a
little chilly; no pain or tumour discoverable in the axilla.
8th: Perfectly well.
9th: The same.
10th: The vesicle more elevated than I have been accustomed to
see it, and assuming more perfectly the variolous character than
is common with the cow-pox at this stage.
11th: Surrounded by an inflammatory redness, about the size of a
shilling, studded over with minute vesicles. The pustule
contained a limpid fluid till the fourteenth day, after which it
was incrusted over in the usual manner; but this incrustation or
scab being accidentally rubbed off, it was slow in healing.
These children were afterwards fully exposed to the smallpox
contagion without effect.
Having been requested by my friend, Mr. Henry Hicks, of
Eastington, in this county, to inoculate two of his children, and
at the same time some of his servants and the people employed in
his manufactory, matter was taken from the arm of this boy for
the purpose. The numbers inoculated were eighteen. They all took
the infection, and either on the fifth or sixth day a vesicle was
perceptible on the punctured part. Some of them began to feel a
little unwell on the eighth day, but the greater number on the
ninth. Their illness, as in the former cases described, was of
short duration, and not sufficient to interrupt, but at very
short intervals, the children from their amusements, or the
servants and manufacturers from following their ordinary
business.
Three of the children whose employment in the manufactory was in
some degree laborious had an inflammation on their arms beyond
the common boundary about the eleventh or twelfth day, when the
feverish symptoms, which before were nearly gone off, again
returned, accompanied with increase of axillary tumour. In these
cases (clearly perceiving that the symptoms were governed by the
state of the arms) I applied on the inoculated pustules, and
renewed the application three or four times within an hour, a
pledget of lint, previously soaked in aqua lythargyri acetati
[Footnote: Goulard's extract of Saturn.] and covered the hot
efflorescence surrounding them with cloths dipped in cold water.
The next day I found this simple mode of treatment had succeeded
perfectly. The inflammation was nearly gone off, and with it the
symptoms which it had produced.
Some of these patients have since been inoculated with variolous
matter, without any effect beyond a little inflammation on the
part where it was inserted.
Why the arms of those inoculated with the vaccine matter in the
country should be more disposed to inflame than those inoculated
in London it may be difficult to determine. From comparing my own
cases with some transmitted to me by Dr. Pearson and Dr.
Woodville, this appears to be the fact; and what strikes me as
still more extraordinary with respect to those inoculated in
London is the appearance of maturating eruptions, In the two
instances only which I have mentioned (the one from the
inoculated, the other from the casual, cow-pox) a few red spots
appeared, which quickly went off without maturating. The case of
the Rev. Mr. Moore's servant may, indeed, seem like a deviation
from the common appearances in the country, but the nature of
these eruptions was not ascertained beyond their not possessing
the property of communicating the disease by their effluvia.
Perhaps the difference we perceive may be owing to some variety
in the mode of action of the virus upon the skin of those who
breathe the air of London and those who live in the country. That
the erysipelas assumes a different form in London from what we
see it put on in this country is a fact very generally
acknowledged. In calling the inflammation that is excited by the
cow-pox virus erysipelatous, perhaps I may not be critically
exact, but it certainly approaches near to it. Now, as the
diseased action going forward in the part infected with the virus
may undergo different modifications according to the
peculiarities of the constitution on which it is to produce its
effect, may it not account for the variation which has been
observed?
To this it may probably be objected that some of the patients
inoculated, and who had pustules in consequence, were newly come
from the country; but I conceive that the changes wrought in the
human body through the medium of the lungs may be extremely
rapid. Yet, after all, further experiments made in London with
vaccine virus generated in the country must finally throw a light
on what now certainly appears obscure and mysterious.
The principal variation perceptible to me in the action of the
vaccine virus generated in London from that produced in the
country was its proving more certainly infectious and giving a
less disposition in the arm to inflame. There appears also a
greater elevation of the pustule above the surrounding skin. In
my former cases the pustule produced by the insertion of the
virus was more like one of those which are so thickly spread over
the body in a bad kind of confluent smallpox. This was more like
a pustule of the distinct smallpox, except that I saw no instance
of pus being formed in it, the matter remaining limpid till the
period of scabbing.
Wishing to see the effects of the disease on an infant newly
born, my nephew, Mr. Henry Jenner, at my request, inserted the
vaccine virus into the arm of a child about twenty hours old. His
report to me is that the child went through the disease without
apparent illness, yet that it was found effectually to resist the
action of variolous matter with which it was subsequently
inoculated.
I have had an opportunity of trying the effects of the cow-pox
matter on a boy, who, the day preceding its insertion, sickened
with the measles. The eruption of the measles, attended with
cough, a little pain in the chest; and the usual symptoms
accompanying the disease, appeared on the third day and spread
all over him. The disease went through its course without any
deviation from its usual habits; and, notwithstanding this, the
cow-pox virus excited its common appearances, both on the arm and
on the constitution, without any febrile interruption; on the
sixth day there was a vesicle.
8th: Pain in the axilla, chilly, and affected with headache.
9th: Nearly well.
12th: The pustule spread to the size of a large split-pea, but
without any surrounding efflorescence. It soon afterwards
scabbed, and the boy recovered his general health rapidly. But it
should be observed that before it scabbed the efflorescence which
had suffered a temporary suspension advanced in the usual manner.
Here we see a deflation from the ordinary habits of the smallpox,
as it has been observed that the presence of the measles suspends
the action of the variolous matter.
The very general investigation that is now taking place, chiefly
through inoculation (and I again repeat my earnest hope that it
may be conducted with that calmness and moderation which should
ever accompany a philosophical research), must soon place the
vaccine disease in its just point of view. The result of all my
trials with the virus on the human subject has been uniform. In
every instance the patient who has felt its influence, has
completely lost the susceptibility for the variolous contagion;
and as these instances are now become numerous, I conceive that,
joined to the observations in the former part of this paper, they
sufficiently preclude me from the necessity of entering into
controversies with those who have circulated reports adverse to
my assertions, on no other evidence than what has been casually
collected.
III
A CONTINUATION OF FACTS AND OBSERVATIONS RELATIVE TO THE VARIOUS
VACCINES, OR COW-POX. 1800
Since my former publications on the vaccine inoculation I have
had the satisfaction of seeing it extend very widely. Not only in
this country is the subject pursued with ardour, but from my
correspondence with many respectable medical gentlemen on the
Continent (among whom are Dr. De Carro, of Vienna, and Dr.
Ballhorn, of Hanover) I find it is as warmly adopted abroad,
where it has afforded the greatest satisfaction. I have the
pleasure, too, of seeing that the feeble efforts of a few
individuals to depreciate the new practice are sinking fast into
contempt beneath the immense mass of evidence which has arisen up
in support of it.
Upwards of six thousand persons have now been inoculated with the
virus of cow-pox, and the far greater part of them have since
been inoculated with that of smallpox, and exposed to its
infection in every rational way that could be devised, without
effect.
It was very improbable that the investigation of a disease so
analogous to the smallpox should go forward without engaging the
attention of the physician of the Smallpox Hospital in London.
Accordingly, Dr. Woodville, who fills that department with so
much respectability, took an early opportunity of instituting an
inquiry into the nature of the cow-pox. This inquiry was begun in
the early part of the present year, and in May, Dr. Woodville
published the result, which differs essentially from mine in a
point of much importance. It appears that three-fifths of the
patients inoculated were affected with eruptions, for the most
part so perfectly resembling the smallpox as not to be
distinguished from them. On this subject it is necessary that I
should make some comments.
When I consider that out of the great number of cases of casual
inoculation immediately from cows which from time to time
presented themselves to my observation, and the many similar
instances which have been communicated to me by medical gentlemen
in this neighbourhood; when I consider, too, that the matter with
which my inoculations were conducted in the years 1797, '98, and
'99, was taken from some different cows, and that in no instance
any thing like a variolous pustule appeared, I cannot feel
disposed to imagine that eruptions, similar to those described by
Dr. Woodville, have ever been produced by the pure uncontaminated
cow-pock virus; on the contrary, I do suppose that those which
the doctor speaks of originated in the action of variolous matter
which crept into the constitution with the vaccine. And this I
presume happened from the inoculation of a great number of the
patients with variolous matter (some on the third, others on the
fifth, day) after the vaccine had been applied; and it should be
observed that the matter thus propagated became the source of
future inoculations in the hands of many medical gentlemen who
appeared to have been previously unacquainted with the nature of
the cow-pox.
Another circumstance strongly, in my opinion, supporting this
supposition is the following: The cow-pox has been known among
our dairies time immemorial. If pustules, then, like the
variolous, were to follow the communication of it from the cow to
the milker, would not such a fact have been known and recorded at
our farms? Yet neither our farmers nor the medical people of the
neighbourhood have noticed such an occurrence.
A few scattered pimples I have sometimes, though very rarely,
seen, the greater part of which have generally disappeared
quickly, but some have remained long enough to suppurate at their
apex. That local cuticular inflammation, whether springing up
spontaneously or arising from the application of acrid
substances, such for instance, as cantharides, pix Burgundica,
antimonium tartarizatum, etc., will often produce cutaneous
affections, not only near the seat of the inflammation, but on
some parts of the skin far beyond its boundary, is a well-known
fact. It is, doubtless, on this principle that the inoculated
cow-pock pustule and its concomitant efflorescence may, in very
irritable constitutions, produce this affection. The eruption I
allude to has commonly appeared some time in the third week after
inoculation. But this appearance is too trivial to excite the
least regard.
The change which took place in the general appearance during the
progress of the vaccine inoculation at the Smallpox Hospital
should likewise be considered.
Although at first it took on so much of the variolous character
as to produce pustules in three cases out of five, yet in Dr.
Woodville's last report, published in June, he says: "Since the
publication of my reports of inoculations for the cow-pox,
upwards of three hundred cases have been under my care; and out
of this number only thirty-nine had pustules that suppurated;
viz., out of the first hundred, nineteen had pustules; out of the
second, thirteen; and out of the last hundred and ten, only seven
had pustules. Thus it appears that the disease has become
considerably milder; which I am inclined to attribute to a
greater caution used in the choice of the matter, with which the
infection was communicated; for, lately, that which has been
employed for this purpose has been taken only from those patients
in whom the cow-pox proved very mild and well characterized."
[Footnote: In a few weeks after the cow-pox inoculation was
introduced at the Smallpox Hospital I was favoured with some
virus from this stock. In the first instance it produced a few
pustules, which did not maturate; but in the subsequent cases
none appeared.--E. J.]
The inference I am induced to draw from these premises is very
different. The decline, and, finally, the total extinction
nearly, of these pustules, in my opinion, are more fairly
attributable to the cow-pox virus, assimilating the variolous,
[Footnote: In my first publication on this subject I expressed an
opinion that the smallpox and the cow-pox were the same diseases
under different modifications. In this opinion Dr. Woodville has
concurred The axiom of the immortal Hauter, that two diseased
actions cannot take place at the same time in one and the same
part, will not be injured by the admission of this theory.]
the former probably being the original, the latter the same
disease under a peculiar, and at present an inexplicable,
modification.
One experiment tending to elucidate the point under discussion I
had myself an opportunity of instituting. On the supposition of
its being possible that the cow which ranges over the fertile
meadows in the vale of Gloucester might generate a virus
differing in some respects in its qualities from that produced by
the animal artificially pampered for the production of milk for
the metropolis, I procured, during my residence there in the
spring, some cow pock virus from a cow at one of the London milk-
farms. [Footnote: It was taken by Mr. Tanner, then a student at
the Veterinary College, from a cow at Mr. Clark's farm at Kentish
Town.] It was immediately conveyed into Gloucestershire to Dr.
Marshall, who was then extensively engaged in the inoculation of
the cow-pox, the general result of which, and of the inoculation
in particular with this matter, I shall lay before my reader in
the following communication from the doctor:
"DEAR SIR:
"My neighbour, Mr. Hicks, having mentioned your wish to be
informed of the progress of the inoculation here for the cow-pox,
and he also having taken the trouble to transmit to you my
minutes of the cases which have fallen under my care, I hope you
will pardon the further trouble I now give you in stating the
observations I have made upon the subject. When first informed of
it, having two children who had not had the smallpox, I
determined to inoculate them for the cow-pox whenever I should be
so fortunate as to procure matter proper for the purpose. I was,
therefore, particularly happy when I was informed that I could
procure matter from some of those whom you had inoculated. In the
first instance I had no intention of extending the disease
further than my own family, but the very extensive influence
which the conviction of its efficacy in resisting the smallpox
has had upon the minds of the people in general has rendered that
intention nugatory, as you will perceive, by the continuation of
my cases enclosed in this letter, [Footnote: Doctor Marshall has
detailed these cases with great accuracy, but their publication
would now be deemed superfluous.--E.J.] by which it will appear
that since the 22d of March I have inoculated an hundred and
seven persons; which, considering the retired situation I resided
in, is a very great number. There are also other considerations
which, besides that of its influence in resisting the smallpox,
appear to have had their weight; the peculiar mildness of the
disease, the known safety of it, and its not having in any
instance prevented the patient from following his ordinary
business. In all the cases under my care there have only occurred
two or three which required any application, owing to
erysipelatous inflammation on the arm, and they immediately
yielded to it. In the remainder the constitutional illness has
been slight but sufficiently marked, and considerably less than I
ever observed in the same number inoculated with the smallpox. In
only one or two of the cases have any other eruptions appeared
than those around the spot where the matter was inserted, and
those near the infected part. Neither does there appear in the
cow-pox to be the least exciting cause to any other disease,
which in the smallpox has been frequently observed, the
constitution remaining in as full health and vigour after the
termination of the disease as before the infection. Another
important consideration appears to be the impossibility of the
disease being communicated except by the actual contact of the
matter of the pustule, and consequently the perfect safety of the
remaining part of the family, supposing only one or two should
wish to be inoculated at the same time.
"Upon the whole, it appears evident to me that the cow-pox is a
pleasanter, shorter, and infinitely more safe disease than the
inoculated smallpox when conducted in the most careful and
approved manner; neither is the local affection of the inoculated
part, or the constitutional illness, near so violent. I speak
with confidence on the subject, having had an opportunity of
observing its effects upon a variety of constitutions, from three
months old to sixty years; and to which I have paid particular
attention. In the cases alluded to here you will observe that the
removal from the original source of the matter had made no
alteration or change in the nature or appearance of the disease,
and that it may be continued, ad infinitum (I imagine), from one
person to another (if care be observed in taking the matter at a
proper period) without any necessity of recurring to the original
matter of the cow.
"I should be happy if any endeavours of mine could tend further
to elucidate the subject, and shall be much gratified is sending
you any further observations I may be enabled to make.
"I have the pleasure to subscribe myself,
"Dear sir, etc.,
"JOSEPH H. MARSHALL
"EASTINGTON, GLOUCESTERSHIRE, April 26, 1799."
The gentleman who favoured me with the above account has
continued to prosecute his inquiries with unremitting industry,
and has communicated the result in another letter, which at his
request I lay before the public without abbreviation.
Dr. Marshall's second letter:
"DEAR SIR:
"Since the date of my former letter I have continued to inoculate
with the cow-pox virus. Including the cases before enumerated,
the number now amounts to four hundred and twenty-three. It would
be tedious and useless to detail the progress of the disease in
each individual--it is sufficient to observe that I noticed no
deviation in any respect from the cases I formerly adduced. The
general appearances of the arm exactly corresponded with the
account given in your first publication. When they were disposed
to become troublesome by erysipelatous inflammation, an
application of equal parts of vinegar and water always answered
the desired intention. I must not omit to inform you that when
the disease had duly acted upon the constitution I have
frequently used the vitriolic acid. A portion of a drop applied
with the head of a probe or any convenient utensil upon the
pustule, suffered to remain about forty seconds, and afterwards
washed off with sponge and water, never failed to stop its
progress and expedite the formation of a scab.
"I have already subjected two hundred and eleven of my patients
to the action of variolous matter, but EVERY ONE RESISTED IT.
"The result of my experiments (which were made with every
requisite caution) has fully convinced me that the TRUE COW-POX
is a safe and infallible preventive from the smallpox; that in no
case which has fallen under my observation has it been in any
considerable degree troublesome, much less have I seen any thing
like danger; for in no instance were the patients prevented from
following their ordinary employments.
"In Dr. Woodville's publication on the cow-pox I notice an
extraordinary fact. He says that the generality of his patients
had pustules. It certainly appears extremely extraordinary that
in all my cases there never was but one pustule, which appeared
on a patient's elbow on the inoculated arm, and maturated. It
appeared exactly like that on the incised part.
"The whole of my observations, founded as it appears on an
extensive experience, leads me to these obvious conclusions; that
those cases which have been or may be adduced against the
preventive powers of the cow-pox could not have been those of the
true kind, since it must appear to be absolutely impossible that
I should have succeeded in such a number of cases without a
single exception if such a preventive power did not exist. I
cannot entertain a doubt that the inoculated cow-pox must quickly
supersede that of the smallpox. If the many important advantages
which must result from the new practice are duly considered, we
may reasonably infer that public benefit, the sure test of the
real merit of discoveries, will render it generally extensive.
"To you, Sir, as the discoverer of this highly beneficial
practice, mankind are under the highest obligations. As a private
individual I participate in the general feeling; more
particularly as you have afforded me an opportunity of noticing
the effects of a singular disease, and of viewing the progress of
the most curious experiment that ever was recorded in the history
of physiology.
"I remain, dear sir, etc.,
"JOSEPH H. MARSHALL."
"P.S. I should have observed that, of the patients I inoculated
and enumerated in my letter, one hundred and twenty-seven were
infected with the matter you sent me from the London cow. I
discovered no dissimilarity of symptoms in these cases from those
which I inoculated from matter procured in this country. No
pustules have occurred, except in one or two cases, where a
single one appeared on the inoculated arm. No difference was
apparent in the local inflammation. There was no suspension of
ordinary employment among the labouring people, nor was any
medicine required.
"I have frequently inoculated one or two in a family, and the
remaining part of it some weeks afterwards. The uninfected have
slept with the infected during the whole course of the disease
without being affected; so that I am fully convinced that the
disease cannot be taken but by actual contact with the matter.
"A curious fact has lately fallen under my observation, on which
I leave you to comment.
"I visited a patient with the confluent smallpox and charged a
lancet with some of the matter. Two days afterwards I was desired
to inoculate a woman and four children with the cow-pox, and I
inadvertently took the vaccine matter on the same lancet which
was before charged with that of smallpox. In three days I
discovered the mistake, and fully expected that my five patients
would be infected with smallpox; but I was agreeably surprised to
find the disease to be genuine cow-pox, which proceeded without
deviating in any particular from my former cases. I afterwards
inoculated these patients with variolous matter, but all of them
resisted its action.
"I omitted mentioning another great advantage that now occurs to
me in the inoculated cow-pox; I mean, the safety with which
pregnant women may have the disease communicated to them. I have
inoculated a great number of females in that situation, and never
observed their cases to differ in any respect from those of my
other patients. Indeed, the disease is so mild that it seems as
if it might at all times be communicated with the most perfect
safety."
I shall here take the opportunity of thanking Dr. Marshall and
those other gentlemen who have obligingly presented me with the
result of their inoculations; but, as they all agree in the same
point as that given in the above communication, namely, the
security of the patient from the effects of the smallpox after
the cow-pox, their perusal, I presume, would afford us no
satisfaction that has not been amply given already. Particular
occurrences I shall, of course, detail. Some of my correspondents
have mentioned the appearance of smallpox-like eruptions at the
commencement of their inoculations; but in these cases the matter
was derived from the original stock at the Smallpox Hospital.
I have myself inoculated a very considerable number from the
matter produced by Dr. Marshall's patients, originating in the
London cow, without observing pustules of any kind, and have
dispersed it among others who have used it with a similar effect.
From this source Mr. H. Jenner informs me he has inoculated above
an hundred patients without observing eruptions. Whether the
nature of the virus will undergo any change from being farther
removed from its original source in passing successively from one
person to another time alone can determine. That which I am now
employing has been in use near eight months, and not the least
change is perceptible in its mode of action either locally or
constitutionally. There is, therefore, every reason to expect
that its effects will remain unaltered and that we shall not be
under the necessity of seeking fresh supplies from the cow.
The following observations were obligingly sent me by Mr. Tierny,
Assistant Surgeon to the South Gloucester Regiment of Militia, to
whom I am indebted for a former report on this subject:
"I inoculated with the cow-pox matter from the eleventh to the
latter part of April, twenty-five persons, including women and
children. Some on the eleventh were inoculated with the matter
Mr. Shrapnell (surgeon to the regiment) had from you, the others
with matter taken from these. The progress of the puncture was
accurately observed, and its appearance seemed to differ from the
smallpox in having less inflammation around its basis on the
first days--that is, from the third to the seventh; but after
this the inflammation increased, extending on the tenth or
eleventh day to a circle of an inch and a half from its centre,
and threatening very sore arms; but this I am happy to say was
not the case; for, by applying mercurial ointment to the inflamed
part, which was repeated daily until the inflammation went off,
the arm got well without any further application or trouble. The
constitutional symptoms which appeared on the eighth or ninth day
after inoculation scarcely deserved the name of disease, as they
were so slight as to be scarcely perceptible, except that I could
connect a slight headache and languor, with a stiffness and
rather painful sensation in the axilla. This latter symptom was
the most striking--it remained from twelve to forty-eight hours.
In no case did I observe the smallest pustule, or even
discolouration of the skin, like an incipient pustule, except
about the part where the virus has been applied.
"After all these symptoms had subsided and the arms were well, I
inoculated four of this number with variolous matter, taken from
a patient in another regiment. In each of these it was inserted
several times under the cuticle, producing slight inflammation on
the second or third day, and always disappearing before the fifth
or sixth, except in one who had the cow-pox in Gloucestershire
before he joined us, and who also received it at this time by
inoculation. In this man the puncture inflamed and his arm was
much sorer than from the insertion of the cow-pox virus; but
there was no pain in the axilla, nor could any constitutional
affection be observed.
"I have only to add that I am now fully satisfied of the efficacy
of the cow-pox in preventing the appearance of the smallpox, and
that it is a most happy and salutary substitute for it. I remain,
etc.,
"M. J. TIERNY."
Although the susceptibility of the virus of the cow-pox is, for
the most part, lost in those who have had the smallpox, yet in
some constitutions it is only partially destroyed, and in others
it does not appear to be in the least diminished.
By far the greater number on whom trials were made resisted it
entirely; yet I found some on whose arm the pustule from
inoculation was formed completely, but without producing the
common efflorescent blush around it, or any constitutional
illness, while others have had the disease in the most perfect
manner. A case of the latter kind having been presented to me by
Mr. Fewster, Surgeon, of Thornbury, I shall insert it:
"Three children were inoculated with the vaccine matter you
obligingly sent me. On calling to look at their arms three days
after I was told that John Hodges, one of the three, had been
inoculated with the smallpox when a year old, and that he had a
full burthen, of which his face produced plentiful marks, a
circumstance I was not before made acquainted with. On the sixth
day the arm of the boy appeared as if inoculated with variolous
matter, but the pustule was rather more elevated. On the ninth
day he complained of violent pain in his head and back,
accompanied with vomiting and much fever. The next day he was
very well and went to work as usual. The punctured part began to
spread, and there was the areola around the inoculated part to a
considerable extent.
"As this is contrary to an assertion made in the Medical and
Physical Journal, No. 8, I thought it right to give you this
information, and remain,
"Dear sir, etc.,
"J. FEWSTER."
It appears, then, that the animal economy with regard to the
action of this virus is under the same laws as it is with respect
to the variolous virus, after previously feeling its influence,
as far as comparisons can be made between the two diseases.
Some striking instances of the power of the cow-pox in suspending
the progress of the smallpox after the patients had been several
days casually exposed to the infection have been laid before me
by Mr. Lyford, Surgeon, of Winchester, and my nephew, the Rev. G.
C Jenner. Mr. Lyford, after giving an account of his extensive
and successful practice in the vaccine inoculation in Hampshire,
writes as follows:
"The following case occurred to me a short time since, and may
probably be worth your notice. I was sent for to a patient with
the smallpox, and on inquiry found that five days previous to my
seeing him the eruption began to appear. During the whole of this
time two children who had not had the smallpox, were constantly
in the room with their father, and frequently on the bed with
him. The mother consulted me on the propriety of inoculating
them, but objected to my taking the matter from their father, as
he was subject to erysipelas. I advised her by all means to have
them inoculated at that time, as I could not procure any
variolous matter elsewhere. However, they were inoculated with
vaccine matter, but I cannot say I flattered myself with its
proving successful, as they had previously been so long and still
continued to be exposed to the variolous infection.
Notwithstanding this I was agreeably surprised to find the
vaccine disease advance and go through its regular course; and,
if I may be allowed the expression, to the total extinction of
the smallpox."
Mr. Jenner's cases were not less satisfactory. He writes as
follows:
"A son of Thomas Stinchcomb, of Woodford, near Berkeley, was
infected with the natural smallpox at Bristol, and came home to
his father's cottage. Four days after the eruptions had appeared
upon the boy, the family (none of which had ever had the
smallpox), consisting of the father, mother, and five children,
was inoculated with vaccine virus. On the arm of the mother it
failed to produce the least effect, and she, of course, had the
smallpox, [Footnote: Under similar circumstances I think it would
be advisable to insert the matter into each arm, which would be
more likely to insure the success of the operation.--E. J.] but
the rest of the family had the cow-pox in the usual way, and were
not affected with the smallpox, although they were in the same
room, and the children slept in the same bed with their brother
who was confined to it with the natural smallpox; and
subsequently with their mother.
"I attended this family with my brother, Mr. H. Jenner."
The following cases are of too singular a nature to remain
unnoticed.
Miss R--, a young lady about five years old, was seized on the
evening of the eighth day after inoculation with vaccine virus,
with such symptoms as commonly denote the accession of violent
fever. Her throat was also a little sore, and there were some
uneasy sensations about the muscles of the neck. The day
following a rash was perceptible on her face and neck, so much
resembling the efflorescence of the scarlatina anginosa that I
was induced to ask whether Miss R--had been exposed to the
contagion of that disease. An answer in the affirmative, and the
rapid spreading of the redness over the skin, at once relieved me
from much anxiety respecting the nature of the malady, which went
through its course in the ordinary way, but not without symptoms
which were alarming both to myself and Mr. Lyford, who attended
with me. There was no apparent deviation in the ordinary progress
of the pustule to a state of maturity from what we see in
general; yet there was a total suspension of the areola or florid
discolouration around it, until the scarlatina had retired from
the constitution. As soon as the patient was freed from this
disease this appearance advanced in the usual way. [Footnote: I
witnessed a similar fact in a case of measles. The pustule from
the cow-pock virus advanced to maturity, while the measles
existed in the constitution, but no EFFLORESCENCE appeared around
it until the measles had ceased to exert its influence.]
The case of Miss H--R--is not less interesting than that of her
sister, above related. She was exposed to the contagion of the
scarlatina at the same time, and sickened almost at the same
hour. The symptoms continued severe about twelve hours, when the
scarlatina-rash shewed itself faintly upon her face, and partly
upon her neck. After remaining two or three hours it suddenly
disappeared, and she became perfectly free from every complaint.
My surprise at this sudden transition from extreme sickness to
health in great measure ceased when I observed that the
inoculated pustule had occasioned, in this case, the common
efflorescent appearance around it, and that as it approached the
centre it was nearly in an erysipelatous state. But the most
remarkable part of this history is that, on the fourth day
afterwards, so soon as the efflorescence began to die away upon
the arm and the pustule to dry up, the scarlatina again appeared,
her throat became sore, the rash spread all over her. She went
fairly through the disease with its common symptoms.
That these were actually cases of scarlatina was rendered certain
by two servants in the family falling ill at the same time with
the distemper, who had been exposed to the infection with the
young ladies.
Some there are who suppose the security from the smallpox
obtained through the cow-pox will be of a temporary nature only.
This supposition is refuted not only by analogy with respect to
the habits of diseases of a similar nature, but by
incontrovertible facts, which appear in great numbers against it.
To those already adduced in the former part of my first treatise
[Footnote: See pages 217, 218, 219, 221, 223, etc.] many more
might be adduced were it deemed necessary; but among the cases I
refer to, one will be found of a person who had the cow-pox
fifty-three years before the effect of the smallpox was tried
upon him. As he completely resisted it, the intervening period I
conceive must necessarily satisfy any reasonable mind. Should
further evidence be thought necessary, I shall observe that,
among the cases presented to me by Mr. Fry, Mr. Darke, Mr.
Tierny, Mr. H. Jenner, and others, there were many whom they
inoculated ineffectually with variolous matter, who had gone
through the cow-pox many years before this trial was made.
It has been imagined that the cow-pox is capable of being
communicated from one person to another by effluvia without the
intervention of inoculation. My experiments, made with the design
of ascertaining this important point, all tend to establish my
original position, that it is not infectious except by contact, I
have never hesitated to suffer those on whose arms there were
pustules exhaling the effluvia from associating or even sleeping
with others who never had experienced either the cow-pox or the
smallpox. And, further, I have repeatedly, among children, caused
the uninfected to breathe over the inoculated vaccine 'pustules
during their whole progress, yet these experiments were tried
without the least effect. However, to submit a matter so
important to a still further scrutiny, I desired Mr. H. Jenner to
make any further experiments which might strike him as most
likely to establish or refute what had been advanced on this
subject. He has since informed me "that he inoculated children at
the breast, whose mothers had not gone through either the
smallpox or the cow-pox; that he had inoculated mothers whose
sucking infants had never undergone either of these diseases;
that the effluvia from the inoculated pustules, in either case,
had been inhaled from day to day during the whole progress of
their maturation, and that there was not the least perceptible
effect from these exposures." One woman he inoculated about a week
previous to her accouchement, that her infant might be the more
fully and conveniently exposed to the pustule; but, as in the
former instances, no infection was given, although the child
frequently slept on the arm of its mother with its nostrils and
mouth exposed to the pustule in the fullest state of maturity. In
a word, is it not impossible for the cow-pox, whose ONLY
manifestation appears to consist in the pustules CREATED BY
CONTACT, to produce ITSELF by effluvia?
In the course of a late inoculation I observed an appearance
which it may be proper here to relate. The punctured part on a
boy's arm (who was inoculated with fresh limpid virus) on the
sixth day, instead of shewing a beginning vesicle, which is usual
in the cow-pox at that period, was encrusted over with a rugged,
amber-coloured scab. The scab continued to spread and increase in
thickness for some days, when, at its edges, a vesicated ring
appeared, and the disease went through its ordinary course, the
boy having had soreness in the axilla and some slight
indisposition. With the fluid matter taken from his arm five
persons were inoculated. In one it took no effect. In another it
produced a perfect pustule without any deviation from the common
appearance; but in the other three the progress of the
inflammation was exactly similar to the instance which afforded
the virus for their inoculation; there was a creeping scab of a
loose texture, and subsequently the formation of limpid fluid at
its edges. As these people were all employed in laborious
exercises, it is possible that these anomalous appearances might
owe their origin to the friction of the clothes on the newly
inflamed part of the arm. I have not yet had an opportunity of
exposing them to the smallpox.
In the early part of this inquiry I felt far more anxious
respecting the inflammation of the inoculated arm than at
present; yet that this affection will go on to a greater extent
than could be wished is a circumstance sometimes to be expected.
As this can be checked, or even entirely subdued, by very simple
means, I see no reason why the patient should feel an uneasy hour
because an application may not be absolutely necessary. About the
tenth or eleventh day, if the pustule has proceeded regularly,
the appearance of the arm will almost to a certainty indicate
whether this is to be expected or not. Should it happen, nothing
more need be done than to apply a single drop of the aqua
lythargyri acetati [Footnote: Extract of Saturn.] upon the
pustule, and, having suffered it to remain two or three minutes,
to cover the efflorescence surrounding the pustule with a piece
of linen dipped in the aqua lythargyri compos. [Footnote: Goulard
water. For further information on this subject see the first
Treatise on the Var. Vac., Dr. Marshall's letters, etc.] The
former may be repeated twice or thrice during the day, the latter
as often as it may feel agreeable to the patient.
When the scab is prematurely rubbed off (a circumstance not
unfrequent among children and working people), the application of
a little aqua lythargyri acet. to the part immediately coagulates
the surface, which supplies its place, and prevents a sore.
In my former treatises on this subject I have remarked that the
human constitution frequently retains its susceptibility to the
smallpox contagion (both from effluvia and contact) after
previously feeling its influence. In further corroboration of
this declaration many facts have been communicated to me by
various correspondents. I shall select one of them.
"DEAR SIR:
"Society at large must, I think, feel much indebted to you for
your Inquiries and Observations on the Nature and Effects of the
Variolae Vaccinae, etc., etc. As I conceive what I am now about
to communicate to be of some importance, I imagine it cannot be
uninteresting to you, especially as it will serve to corroborate
your assertion of the susceptibility of the human system of the
variolous contagion, although it has previously been made
sensible of its action. In November, 1793, I was desired to
inoculate a person with the smallpox. I took the variolous matter
from a child under the disease in the natural way, who had a
large burthen of distinct pustules. The mother of the child being
desirous of seeing my method of communicating the disease by
inoculation, after having opened a pustule, I introduced the
point of my lancet in the usual way on the back part of my own
hand, and thought no more of it until I felt a sensation in the
part which reminded me of the transaction. This happened upon the
third day; on the fourth there were all the appearances common to
inoculation, at which I was not at all surprised, nor did I feel
myself uneasy upon perceiving the inflammation continue to
increase to the sixth and seventh day, accompanied with a very
small quantity of fluid, repeated experiments having taught me it
might happen so with persons who had undergone the disease, and
yet would escape any constitutional affection; but I was not so
fortunate; for on the eighth day I was seized with all the
symptoms of the eruptive fever, but in a much more violent degree
than when I was before inoculated, which was about eighteen years
previous to this, when I had a considerable number of pustules. I
must confess I was now greatly alarmed, although I had been much
engaged in the smallpox, having at different times inoculated not
less than two thousand persons. I was convinced my present
indisposition proceeded from the insertion of the variolous
matter, and, therefore, anxiously looked for an eruption. On the
tenth day I felt a very unpleasant sensation of stillness and
heat on each side of my face near my ear, and the fever began to
decline. The affection in my face soon terminated in three or
four pustules attended with inflammation, but which did not
maturate, and I was presently well.
"I remain, dear sir, etc.,
"THOMAS MILES."
This inquiry is not now so much in its infancy as to restrain me
from speaking more positively than formerly on the important
point of scrophula as connected with the smallpox.
Every practitioner in medicine who has extensively inoculated
with the smallpox, or has attended many of those who have had the
distemper in the natural way, must acknowledge that he has
frequently seen scrophulous affections, in some form or another,
sometimes rather quickly shewing themselves after the recovery of
the patients. Conceiving this fact to be admitted, as I presume
it must be by all who have carefully attended to the subject, may
I not ask whether it does not appear probable that the general
introduction of the smallpox into Europe has not been among the
most conductive means in exciting that formidable foe to health?
Having attentively watched the effects of the cow-pox in this
respect, I am happy in being able to declare that the disease
does not appear to have the least tendency to produce this
destructive malady.
The scepticism that appeared, even among the most enlightened of
medical men when my sentiments on the important subject of the
cow-pox were first promulgated, was highly laudable. To have
admitted the truth of a doctrine, at once so novel and so unlike
any thing that ever had appeared in the annals of medicine,
without the test of the most rigid scrutiny, would have bordered
upon temerity; but now, when that scrutiny has taken place, not
only among ourselves, but in the first professional circles in
Europe, and when it has been uniformly found in such abundant
instances that the human frame, when once it has felt the
influence of the genuine cow-pox in the way that has been
described, is never afterwards at any period of its existence
assailable by the smallpox, may I not with perfect confidence
congratulate my country and society at large on their beholding,
in the mild form of the cow-pox, an antidote that is capable of
extirpating from the earth a disease which is every hour
devouring its victims; a disease that has ever been considered as
the severest scourge of the human race!
THE CONTAGIOUSNESS OF PUERPERAL FEVER
BY
OLIVER WENDELL HOLMES
INTRODUCTORY NOTE
Oliver Wendell Holmes was born in Cambridge, Massachusetts,
August 29, 1809, and educated at Phillips Academy, Andover, and
Harvard College. After graduation, he entered the Law School, but
soon gave up law for medicine. He studied first in Boston, and
later spent two years in medical schools in Europe, mainly in
Paris. On his return he began to practise in Boston, but in two
years he was appointed professor of anatomy at Dartmouth College,
a position which he held from 1838 to 1840, when he again took up
his Boston practise. It was soon after this, in 1843, that he
published his essay on the "Contagiousness of Puerperal Fever,"
his only contribution of high distinction to medical science.
From 1847 to 1882 he was Parkman professor of anatomy and
physiology in the Harvard Medical School. He died in Boston,
October 7, 1894.
In spite of the importance of the paper here printed, Holmes's
reputation as a scientist was overshadowed by that won by him as
a wit and a man of letters. When he was only twenty-one his "Old
Ironsides" brought him into notice; and through his poetry and
fiction, and the sparkling talk of the "Breakfast Table" series,
he took a high place among the most distinguished group of
writers that America has yet produced.
THE CONTAGIOUSNESS OF PUERPERAL FEVER
Note.--This essay appeared first in 1843, in The New England
Quarterly Journal of Medicine, and was reprinted in the "Medical
Essays" in 1855.
In collecting, enforcing and adding to the evidence accumulated
upon this most serious subject, I would not be understood to
imply that there exists a doubt in the mind of any well-informed
member of the medical profession as to the fact that puerperal
fever is sometimes communicated from one person to another, both
directly and indirectly. In the present state of our knowledge
upon this point I should consider such doubts merely as a proof
that the sceptic had either not examined the evidence, or, having
examined it, refused to accept its plain and unavoidable
consequences. I should be sorry to think, with Dr. Rigby, that it
was a case of "oblique vision"; I should be unwilling to force
home the argumentum ad hominem of Dr. Blundell, but I would not
consent to make a question of a momentous fact which is no longer
to be considered as a subject for trivial discussions, but to be
acted upon with silent promptitude. It signifies nothing that
wise and experienced practitioners have sometimes doubted the
reality of the danger in question; no man has the right to doubt
it any longer. No negative facts, no opposing opinions, be they
what they may, or whose they may, can form any answer to the
series of cases now within the reach of all who choose to explore
the records of medical science.
If there are some who conceive that any important end would be
answered by recording such opinions, or by collecting the history
of all the cases they could find in which no evidence of the
influence of contagion existed, I believe they are in error.
Suppose a few writers of authority can be found to profess a
disbelief in contagion,--and they are very few compared with
those who think differently,--is it quite clear that they formed
their opinions on a view of all the facts, or is it not apparent
that they relied mostly on their own solitary experience? Still
further, of those whose names are quoted, is it not true that
scarcely a single one could, by any possibility, have known the
half or the tenth of the facts bearing on the subject which have
reached such a frightful amount within the last few years? Again,
as to the utility of negative facts, as we may briefly call
them,--instances, namely, in which exposure has not been followed
by disease,--although, like other truths, they may be worth
knowing, I do not see that they are like to shed any important
light upon the subject before us. Every such instance requires a
good deal of circumstantial explanation before it can be
accepted. It is not enough that a practitioner should have had a
single case of puerperal fever not followed by others. It must be
known whether he attended others while this case was in progress,
whether he went directly from one chamber to others, whether he
took any, and what, precautions. It is important to know that
several women were exposed to infection derived from the patient,
so that allowance may be made for want of predisposition. Now, if
of negative facts so sifted there could be accumulated a hundred
for every one plain instance of communication here recorded, I
trust it need not be said that we are bound to guard and watch
over the hundredth tenant of our fold, though the ninety and nine
may be sure of escaping the wolf at its entrance. If any one is
disposed, then, to take a hundred instances of lives, endangered
or sacrificed out of those I have mentioned, and make it
reasonably clear that within a similar time and compass TEN
THOUSAND escaped the same exposure, I shall, thank him for his
industry, but I must be permitted to hold to my own practical
conclusions, and beg him to adopt or at least to examine them
also. Children that walk in calico before open fires are not
always burned to death; the instances to the contrary may be
worth recording; but by no means if they are to be used as
arguments against woollen frocks and high fenders.
I am not sure that this paper will escape another remark which it
might be wished were founded in justice. It may be said that the
facts are too generally known and acknowledged to require any
formal argument or exposition, that there is nothing new in the
positions advanced, and no need of laying additional statements
before the profession. But on turning to two works, one almost
universally, and the other extensively, appealed to as authority
in this country, I see ample reason to overlook this objection.
In the last edition of Dewees's Treatise on the "Diseases of
Females" it is expressly said, "In this country, under no
circumstance that puerperal fever has appeared hitherto, does it
afford the slightest ground for the belief that it is
contagious." In the "Philadelphia Practice of Midwifery" not one
word can be found in the chapter devoted to this disease which
would lead the reader to suspect that the idea of contagion had
ever been entertained. It seems proper, therefore, to remind
those who are in the habit of referring to the works for guidance
that there may possibly be some sources of danger they have
slighted or omitted, quite as important as a trifling
irregularity of diet, or a confined state of the bowels, and that
whatever confidence a physician may have in his own mode of
treatment, his services are of questionable value whenever he
carries the bane as well as the antidote about his person.
The practical point to be illustrated is the following: THE
DISEASE KNOWN AS PUERPERAL FEVER IS SO FAR CONTAGIOUS AS TO BE
FREQUENTLY CARRIED FROM PATIENT TO PATIENT BY PHYSICIANS AND
NURSES.
Let me begin by throwing out certain incidental questions, which,
without being absolutely essential, would render the subject more
complicated, and by making such concessions and assumptions as
may be fairly supposed to be without the pale of discussion.
1. It is granted that all the forms of what is called puerperal
fever may not be, and probably are not, equally contagious or
infectious. I do not enter into the distinctions which have been
drawn by authors, because the facts do not appear to me
sufficient to establish any absolute line of demarcation between
such forms as may be propagated by contagion and those which are
never so propagated. This general result I shall only support by
the authority of Dr. Ramsbotham, who gives, as the result of his
experience, that the same symptoms belong to what he calls the
infectious and the sporadic forms of the disease, and the opinion
of Armstrong in his original Essay. If others can show any such
distinction, I leave it to them to do it. But there are cases
enough that show the prevalence of the disease among the patients
of a single practitioner when it was in no degree epidemic; in
the proper sense of the term. I may refer to those of Mr.
Roberton and of Dr. Peirson, hereafter to be cited, as examples.
2. I shall not enter into any dispute about the particular MODE
of infection, whether it be by the atmosphere the physician
carries about him into the sick-chamber, or by the direct
application of the virus to the absorbing surfaces with which his
hand comes in contact. Many facts and opinions are in favour of
each of these modes of transmission. But it is obvious that, in
the majority of cases, it must be impossible to decide by which
of these channels the disease is conveyed, from the nature of the
intercourse between the physician and the patient.
3. It is not pretended that the contagion of puerperal fever must
always be followed by the disease. It is true of all contagious
diseases that they frequently spare those who appear to be fully
submitted to their influence. Even the vaccine virus, fresh from
the subject, fails every day to produce its legitimate effect,
though every precaution is taken to insure its action. This is
still more remarkably the case with scarlet fever and some other
diseases.