Read Ebook: 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 by Dimsdale Thomas

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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 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 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 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 oeconomy 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 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.

The former method of covering the place of incision with a plaister, and continuing upon it dressings of one sort or another, prevented much useful information of this kind. They prevented any judgment by the touch, and sometimes rendered that by the eye equivocal.

The day after the operation is performed, though it takes effect, little alteration is discoverable. On the second day, if the part is viewed with a lens, there generally appears a kind of orange-coloured stain about the incision, and the surrounding skin seems to contract. At this time I usually give the following medicine at going to bed, either mixed with a little of any kind of jelly, or more frequently made into a pill.

Calomel and compound powder of crabs claws, of each 3 grains, emetic tartar 1/10 of a grain.

A quantity of this medicine should be carefully prepared at once, in order to make the division more exact.

On the fourth or fifth day, upon applying the finger, a hardness is to be felt by the touch. The patient perceives an itching on the part, which appears slightly inflamed; and under a kind of vesication is seen a little clear fluid; the part resembling a superficial burn. About the sixth, most commonly, some pain and stiffness is felt in the axilla; and this is a very pleasing symptom, as it not only foretells the near approach of the eruptive symptoms, but is a sign of a favourable progress of the disease. Sometimes on the seventh, oftener on the eighth day, symptoms of the eruptive fever appear; such as slight remitting pains in the head and back, succeeded by transient shiverings and alternate heats, which in a greater or less degree, continue till the eruption is perfected. At this time also it is usual for the patient to complain of a very disagreeable taste in his mouth, the breath is always fetid, and the smell of it different from what I have ever observed in any case, except in the variolous eruptive fever.

The inflammation in the arms at this time spreads fast; and upon viewing it with a good glass, the incision, for the most part, appears surrounded with an infinite number of small confluent pustules, which increase in size and extent as the disease advances. On the tenth or eleventh day, a circular or oval efflorescence is usually discovered, surrounding the incision, and extending sometimes near half round the arm, but more frequently to about the size of a shilling; and being under the cuticle, is smooth to the touch, and not painful. This appearance is also a very pleasing one; it accompanies eruption; every disagreeable symptom ceases; and at the same time it certainly indicates the whole affair to be over; the pain and stiffness in the axilla also going off.

The feverish symptoms are for the most part so mild, as seldom to require any medicinal assistance, except a repetition of the same medicine that was directed on the second night after the operation; and on the following morning this laxative draught, to procure three or four stools;

Infusion of sena two ounces, manna half an ounce, tincture of jalap two drams.

These are given as soon as the eruptive symptoms are perceivable, if they seem to indicate any uncommon degree of vehemence.

It has been observed, that by attending to the progress of infection, we may be able to prognosticate, with some degree of certainty, the event of the distemper in general. Particular incidents will ever happen, but not sufficient to destroy the propriety of general rules.

If the appearances already described are observed early, a very favourable event is implied: but it happens in some cases, although it may be perceived that the inoculation has succeeded, yet it is barely perceptible; the colour about the wound remaining pale, instead of changing to red or inflamed; the edges of the incision spread but little, they remain flat, scarcely rising at all, and are attended neither with itching or uneasiness of any kind. Nay, sometimes on the fifth, and even the sixth-day, the alteration is so little, as to make it doubtful whether the infection has taken place.

When matters are in this state, the appearance is unfavourable, and implies a late and more untoward disease: to prevent which, I direct the powder or pill to be taken each night; and in case it fails to operate by stool, or there is the least disposition to costiveness, an ounce of Glauber's salts, or more commonly the laxative draught already mentioned, is given in the morning, once or twice, as the case may require. This course forwards the inflammation, which I always wish to see; as I have constantly observed, that an early progress on the arm, and an early commencement of the eruptive complaints, portend that the distemper will be mild and favourable; and on the contrary, where both are late, the symptoms are usually more irregular and untoward.

Being now arrived at the most interesting period of this distemper, the eruption, a period in which the present practice I am about to recommend, differs essentially from the method heretofore in use, and on the right management of which much depends, it will be requisite to give clear and explicit directions on this head, and to advise their being pursued with firmness and moderation.

Instead of confining the patient to his bed, or his room, when the symptoms of the eruptive fever come on, he is directed, as soon as the purging medicine has operated, to keep abroad in the open air, be it ever so cold, as much as he can bear, and to drink cold water, if thirsty; always taking care not to stand still, but to walk about moderately, while abroad.

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