The Present Method of Inoculating for the Small-Pox

In a few instances also there has been a slough in the incised part, which has made a sore of short duration; but not one instance of an ulcer of any continuance. Such little breakings out too, and scabs, as are frequently known to succeed the mild natural small-pox, sometimes, though rarely, happen to those inoculated this way; and as they are of the same little consequence, are generally cured by the same method of a few gentle purges.

With regard to ophthalmies from this kind of practice, I have never had an example of one truly deserving that name; the coats of the eye have been a little inflamed in a very few, but they soon became clear, without any means used for that purpose. And I know but two cases where I thought the inflammation great enough to require bleeding, and not one where a blister was necessary. So that these complaints, heretofore so frequent and grievous, seem by this new method to be much reduced: a circumstance which, if it does not amount to a proof, admits at least of a fair conjecture, that the state of health is better here, than where those remains of putridity are so evidently existing in the habit.

Discoveries in physic, as in every other science, are in their infancy liable to censure and opposition; and as the present system of inoculation is of so extraordinary a kind, it would not be strange if a greater portion of both than usual should fall to its share. Accordingly, since no charge of fatality during the disease, nor instances of bad effects soon after the recovery, can be produced, recourse has been had to other measures to calumniate and discredit the practice. It would be tedious to enter into a detail of the many false and ridiculous reports that have been spread against it. In general, the constitution is said to be injured, and the dreadful effects are to appear at some distant period; but at what time, or what kind of disease, nobody pretends to determine. To these general accusations it cannot be expected I should give other than a general answer; which is, that from the strictest observation and inquiry I have been able to make, those who have been inoculated in this way, have continued to enjoy as good a state of health as their neighbours; nay, many of them have thought their constitutions better after the process than before.

But it seems as if these opposers expected that inoculation should not only free the inoculated from the small-pox, and any early bad effects, but must preserve them too from all other disorders through the rest of their lives. To such I can say nothing; but if others, who are more reasonable, require further satisfaction as to the consequences of this method, I must desire them to make inquiry of those who have been inoculated under my direction.

Another charge against this method of inoculation is, that some have had the distemper afterwards in the natural way. What I have said under the head of anomalous small-pox, will I believe sufficiently account for the appearances which have occasioned these false reports; and if that does not satisfy, I can only add this positive declaration, that nothing of the kind has ever happened to any patient inoculated by me; and I firmly believe, no one has ever had, or can have, the distemper a second time, either in the natural way or from inoculation.

The Effects of this Treatment applied to the natural Small-Pox

The very great relief which persons under inoculation experience from fresh air, cold water, and evacuations by stool, during the fever preceding eruption, soon determined me to make trial how far the like treatment might be useful to those who might be seized with the small-pox in the natural way; more especially in such cases, where, from the violence of the symptoms, a confluent kind was justly to be apprehended.

But opportunities of making experiments of this sort in a satisfactory manner are rare. First, because a physician, or even medical assistance of any kind, is not often called in till the eruption shews itself; when it is too late to expect all the good effects that might be hoped for, from an earlier trial of this method: and secondly, because the first attack of the small-pox is so much like the beginning of some other fevers as not easily to be distinguished; though a diligent attention to the symptoms, will generally, if we are called in time, enable us to form a pretty certain prognostic. For if the attack of the cold fit be pretty severe, and the subsequent fever unusually high; if a nausea and vomiting succeed, together with great pains in the head, back, and loins, especially in the last; if a delirium, great restlessness, disagreeable taste in the mouth, and a peculiar fœtid smell in the breath, or even if several of these symptoms are observed, the small-pox may with great reason be expected; and if upon inquiry, which should always be made, it appears that the patient has been in the way of infection, there will be little reason to doubt it.

It may be objected, that notwithstanding the closest attention and inquiry, symptoms of the like nature may precede fevers of other kinds; to which I answer, that some such cases, though few, have happened; and the treatment I am about to recommend has been practised not only without prejudice to the patient, but manifestly to his benefit.

But waving for the present all considerations respecting the treatment of fevers in general, I shall only relate what has occurred to me in respect to the natural small-pox.

In several instances where I have been concerned, and where the symptoms and other concurring circumstances induced me to think the small-pox was at hand, I have directed the like management as I recommend to inoculated patients5.

I have been called also to others at the time of eruption, where some pustules having already appeared, made the matter clear; and in every case of this kind, I have endeavoured to get the sick person into the open air, have generally given the mercurial and antimonial pill, and directed a laxative to be taken some hours after it, in order to procure three or four stools; and this method I have more particularly enjoined, and sometimes repeated, where the kind has appeared to be bad, and where little or no relief has been found from the partial eruption; the symptoms continuing to be such as portended great danger. I have followed the same method during every part of the eruptive fever, intending thereby to abate its violence, to check the eruption, and prevent the conflux, and consequently the danger6.

The success attending this practice has hitherto exceeded my expectations; though it must be confessed, that as the symptoms run much higher in the natural, than they are found to do in the inoculated disease, the relief has not been so considerable; and I have found it extremely difficult to persuade such whose complaints have been very severe, to quit their beds, and attempt to go abroad: indeed the exceeding feeble state they are sometimes in, sufficiently shews that great resolution is requisite to put this in practice.

Among those who have been treated in this manner under my own care and inspection, not one has died, and the number amounts to about 40. Some of the most remarkable cases will be subjoined, which will more satisfactorily explain the practice, and demonstrate its success.

The immediate sensible effects of going into the open air, are, a very great abatement of heat upon the whole surface of the skin, which, though but just before intensely hot, generally in a short time feels not much warmer than that of a person in health: the pulse, from being very strong, full, and quick, becomes less hard and full, but continues quick; and I have sometimes observed it to intermit; which, however alarming it may seem, is not a dangerous symptom.

The pain in the head is always relieved, but that in the back and loins does not abate in proportion: and although it costs no little pain and trouble to persist in moving abroad under such circumstances, attended for the most part with great lassitude, yet the patients are sensible of the benefits they receive; and entertaining a good opinion of the usefulness of the practice, commonly behave with great resolution; and, what is very encouraging, in general think themselves stronger.

Upon going within doors to rest themselves, the pain in the head grows worse, but is again relieved as soon as they return into the air.

The effects of the medicines are usually these:

If there has been much sickness at stomach, a vomiting frequently happens soon after the pill: this the patients should promote by drinking plentifully of some warm diluents; and till the fatigue occasioned by it is over, they certainly ought not to go abroad.

By this operation, and the stools which succeed, the feverish and internal heat, the thirst, sickness, and pains, are for the most part considerably abated. The patients commonly complain of being very low and faint after these evacuations; but the most urgent symptoms being alleviated thereby, a disposition to receive nourishment hourly increases. They are then allowed to drink thin mutton or chicken broth, milk pottage, or tea, as the most grateful and refreshing cordial sustenance they can take. Sleep likewise now most commonly comes on spontaneously. But they are permitted to enjoy this refreshment by day upon the bed only; for I always dissuade them from going into it till night.

From the foregoing account it appears, that the fever preceding eruption, and the most grievous symptoms accompanying it, are often greatly mitigated by this practice; and I will here add, that the eruption is most certainly retarded, that is, it does not appear so soon after the attack of the disease, nor come out so precipitately when it has begun to appear, as it seemed likely to have done if the natural progress had not been interrupted; an effect, which, however dangerous it may have been thought, may be produced with the utmost safety, and clearly shews the utility of the practice. For it is evident from experience, that the later the eruption shews itself after the beginning of the disease, and the slower it comes out, the more mild and favourable is the subsequent disorder. And I am of opinion, that the eruption is not only retarded and protracted by this method, but likewise that it is in some degree repressed; having had strong reasons to apprehend, in several instances, that the number of pustules, which appeared at first, were by such repression actually diminished; and those that remained seemed larger, and of a milder kind.

What has hitherto been said on the subject, relates only to the disease in its eruptive state, which is certainly a very interesting period; but that which follows is not less so, though not always attended to so much as it deserves: for when the eruption is completed, the symptoms abate, the patients seem relieved, and often to such a degree, that both they, and their attendants, flatter themselves with hopes of a happy event, and think it unnecessary to apply for any medical assistance; yet with all these hopeful appearances, the number and kind of the small-pox are frequently such, as would make a judicious practitioner apprehensive of much danger in the subsequent stages.

And where the practitioners themselves may see reason to doubt of the event, yet few or none of them have attempted, I believe, to do much towards preventing the danger; for, unless some pressing symptoms call for immediate relief, it is the general practice to wait till maturation comes on, and brings with it such a train of dreadful complaints, as are more than enough to employ, and too often baffle the best abilities.

In this neglected interval, from the eruption being completed, to the accession of the fever of maturation, and its concomitants (an interval which, in point of duration, is very different in different constitutions and kinds of small-pox); I will venture in general to recommend the same mercurial antimonial medicine as was prescribed in the eruptive fever, to be repeated at proper intervals, till the maturation advances; at which time it must certainly be discontinued: and these circumstances can be regulated only by those who attend, according to the urgency of the symptoms, and the strength of the patients: a cupful of the following apozem should, if necessary, be now-and-then taken after the mercurial medicine; often enough to procure three or four stools a day, especially if the patient is costive.

Take cream of tartar, two drachms; of manna, one ounce; dissolve them in one quart of barley water, or the pectoral drink.

How far it may be safe or advisable for the patients to venture out into the open air during this stage of the disease, I will not yet pretend to say; but they will certainly be both refreshed and invigorated, by being kept out of bed as much as they can bear, without being over-fatigued; and by fresh air let in sometimes through an open window.

As the violence of the eruptive fever, with its attendant complaints, must necessarily exhaust the strength and spirits, both should in this interval be recruited, by as much proper nourishment (such as has been mentioned in the former part of this chapter) as can be taken down without offending the stomach; and also, if occasion requires, with medicines of a cordial and anodyne quality: for this is the time to recover as much strength as possible, in order to be better able to encounter and bear the pain and fever, which will most certainly happen, as the state of maturation advances.

Medicines, except what have been already mentioned, seem at this time unnecessary; and they would interfere with, and prevent the true relish for, food.

But for the best method of treating the small-pox in its most dangerous stage, I mean that of maturation, I must refer to the several learned and eminent practitioners who have professedly written upon the subject, whose opinions and practice I neither pretend to correct or amend. I shall however take the liberty to recommend one medicine to be used in that stage of the disease, which I have found to abate heat, and allay thirst, in such a manner as to afford a very pleasing refreshment.

Take of the weak spirit of vitriol one part, of the sweet spirit of vitriol two parts; mix. Of this the quantity of half an ounce may be added to a quart, or perhaps three pints, of barley water, or the pectoral drink, or any other diluent, and to be drank of at pleasure.

I have at present nothing farther to recommend; but what has been said will I presume be sufficient, with the cases annexed (in which the method will be more plainly described) to justify farther trials of the cooling, repelling, and evacuating practice in the beginning, at least, of the natural small-pox, till the eruption is completed; especially where the physician has an opportunity of making the trial before the eruption appears, and can be pretty certain, or has good reason to conclude, that his patient’s disorder is variolous. And the more violent the symptoms are in this stage of the disease, the more we should be induced to employ the means which have been attended with so much success, in the same stage of the disease after inoculation.

But it may be asked, if I was called to a patient in a bad confluent small-pox, and finding the eruption completed, whether in such a case I should venture to give and continue the use of the alterative and purgative medicine; and advise the patient to go out, if he can bear it, into the open air in cold weather, or direct air to be let in through a window even while the mercurial purge may be operating.

Before I give a direct answer to this question, let me first ask the most experienced practitioner, whether he knows any method of cure which may in bad cases be safely relied on, to avert the impending danger, and save his patients? The too well known fatality of all kinds of small-pox, very clearly proves that he does not, and that no such method has yet been discovered. And if this be the case, surely a bold, and even hazardous practice, is very justifiable towards any such unhappy patients, who lie as it were under sentence of a cruel death, not to be prevented by what are called the regular and usual methods. But still it may be urged, that no impending danger, however great, can sufficiently justify the trial of any hazardous experiment, unless supported by some degree of reason or experience. Happy, indeed, it is, when we have these two guides before us; but when they are separated, the latter is certainly most to be relied on, and her I have endeavoured hitherto to follow.

For in the practice of inoculation experience has taught me, that after as well as before the eruption, persons may safely take mercurial purges, and go out during their operation (though I have seldom advised any to do so) into the cold air, in inclement weather, without suffering the least harm or subsequent ill consequence from it. And by this experience I was led, though with great caution, to try whether the same practice might not be safely employed in the cure of the natural small-pox, as well as the inoculated; nor have the trials been unsuccessful: for though among the patients I have treated in this manner, some had confluent sorts, yet were the complaints unusually moderate throughout the whole progress of the disease, and the maturation was completed, without such troublesome and alarming symptoms and events as might be expected under any other known method of treatment; nor did any secondary fever ensue.

I would not, however, be understood to entertain so good an opinion of this method, as to insinuate that it will save all who have the bad confluent kind; too many of these are incurable; but I am not without hopes, that it may give a chance of recovery, hitherto untried, to many: and even if this alterative and evacuating course in the early part of the disease should not succeed, so as to avert the approaching danger, I think there is great reason to suppose that nourishment, cordials, and opiates, which may be wanted in the state of maturation, will be administered with more advantage and security after it, than if that method had not been previously taken.

It seems necessary, however, to declare, that nothing which has been said is meant to relate to practice in the bleeding or purple small-pox; though very cold repellent methods may perhaps deserve to be tried in these hitherto fatal cases, provided it can be done early; but the mercurial evacuating course seems quite improper.

Upon the whole, what has been said on the natural small-pox, must wait the award of time and experience, the only tests of the utility of any practice; for I have lived long enough to have seen several instances where very ingenious and well-meaning men have been greatly mistaken, by relying too much on the first impressions made by a few successful experiments.

Conclusion

Before I dismiss the subject, it may not be improper to give some account of the motives that induced me to adopt this method.

During the course of many years practice of inoculating in the former usual method, I generally committed to writing the most remarkable occurrences to have recourse to. Among these, I had recorded some cases, which proved, that those who had suffered most, were in general such as have been kept warm, and nursed with the greatest tenderness and care. These facts disposed me to think of a cooler manner of treating the disease, and made me attentive to the reports of such a method having been practised in some parts of this country with great success, though too extravagant at first to deserve credit.

The reports, however, of this practice still gained ground; and, upon the strictest inquiry, I found they were for the most part true, and that such who were treated in this way, passed through the distemper in a more favourable manner than my own patients, or those of the most able practitioners in the old method of inoculation; also that the inoculators in this new way, enjoined a stricter regimen as to diet, than I had hitherto thought necessary; and that they frequently brought their uninfected patients into the presence of those who had the disease, and inoculated them immediately with fluid matter, taken on the point of a lancet, and by a very slight puncture or incision; applying no dressing or covering afterwards.

This way of performing the operation pleased me, as far as related to the slightness of the incision, and the use of fresh matter; for I had (in common with other inoculators) sometimes failed of infecting, by using a thread that had been kept too long in a phial: but the circumstance of bringing the person to be inoculated into the presence of one who had the small-pox, seemed hazardous, lest there might be an accumulation of infection.

All doubts, however, were at last removed by the authenticated accounts that I received of these particulars, and of the good success that attended the practice; and I began to try it in January 1765; when, after having directed a strict regimen and some mercurial purges, I inoculated with fluid matter, proceeding with much circumspection and attention; my patients being exposed to the open air in that cold season. The great advantage they received from this treatment was soon apparent, and more than sufficient to encourage my continuance in the practice; till repeated experiments induced me to think, that instead of supposing the fever in the small-pox to be the instrument employed by nature to subdue and expel the variolous poison, we should rather consider it as her greatest enemy, which, if not vigorously restrained, is apt to produce much danger; and that all such means should be used as are most likely to control its violence, and extinguish the too great fervor of the blood. Pursuant to this opinion, besides keeping my patients in the open air, which I had learned from others, I first directed the mercurial and antimonial medicine, and the laxative course in the eruptive state; the manner of administering which, and the success attending, has been already related.

It may perhaps appear singular that bleeding has neither been once mentioned or directed in the course of this work, though by general consent it is allowed to be the most efficacious remedy in all inflammatory cases. To this I can only say, that the regimen and medicine above prescribed commonly reduce the patients so much as to render bleeding unnecessary. And in the natural small-pox it seemed most reasonable to adhere, as strictly as possible, to those measures which had contributed apparently so much towards passing so easily through inoculation. I doubt not, however, that cases will arise, in which bleeding may not only be safe, but extremely salutary.

It will, I hope, be needless to tell the reader, that I have disclosed the whole of what I know with certainty relative to this process, as the regimen, medicines, different types of the disease, the rules of prognostic, and various events, &c. are fully and faithfully related, according to the best of my judgment and experience. And I believe, if the method now recommended is carefully pursued, it will be found to answer with a success at least equal to any yet discovered. Nevertheless it is reasonable to suppose, that further experience may produce some improvements: yet when it is considered, how short a time is required for preparation; how few medicines are to be taken; that those medicines are neither nauseous in themselves, nor violent in their operation, and of a kind likely to be beneficial to most constitutions, and hurtful to none, unless injudiciously administered; that the disease is usually so mild, as to require little or no confinement (the complaints of far the greater number being that they have too little of the distemper); and that the disagreeable consequences which sometimes happened after the former method of inoculation are likewise by this most commonly obviated; I do not see that much alteration can be even wished for. That which appears most likely to be made, is in shortening the time of preparation; for as I have often been obliged to inoculate without any, and have always had the same success, it has inclined me to think, that much, if not the whole, of this process, may be dispensed with, except in very full habits, or where other particular circumstances may require it. But in all these cases, from the insertion of the matter to the time of the eruptive complaints, the patients have been kept to a close observance of diet, and the use of the preparatory medicines, proportioned as well as I could to their condition: for I durst not, by way of experiment, dispense with the use of measures that had been hitherto so successful.