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