*%HK£= .B1MN.I iv1* THE NEW METHOD O F INOCULATING r O R T H SMALL P ,&%X.%\. DELIVER ED /* In a LECTURE in the VERSITY of PHILADELPHIA, Feb. 20th, 1781. / by BENJAMIN RUSH, M. D. Philadelphia, Printed by CHARLES CIST, in Market-Street. M.DCC.LXXXI. T 0 T H E STUDENTS of MEDICINE IN THE Medical School of Philadelphia THE FOLLOWING LECTURE IS INSCRIBED; ■N AS A TESTIMONV OF THE CONSTANT AND PUNCTUAL ATTENDANCE, WITH WHICH THEY WERE PLEASED TO HONOUR THK LECTURES UPON THE PRACTICE OF PHY- SIC. Delivered (at their request) in THE WINTER OF I78O—I. 0 By their Friend and humble servant the AUTHOR,' fc * Gentlemen, IT muft afford no fmall pleafure to a bene- volent mind in the midft of a war, which daily makes fo much havock with the human fpecies, to refledt, that the fmall-pox which once proved equally fatal to thoufands, has been checked in its career, and in a great degree fub- daed by the pra&ice of Inoculation. It is foreign to my purppfe to deliver to you the hiftory of this art, and to mark the various fteps ^that have attended its prbgrefs to its prefent ftate of improvement. We have yet to lament the want of uniformity and of equal fuccefs in the practice pf it among phyficians. A great number of pamphlets have been written upon the fubjett without exhauiling it. There is ftill ample room left for the man of genius to exercife his talents for obfervation and rea- foning on it. The fadts I mean to lay befqre you are fo inconfiderable, compared with what ftill remain to be known upon this fubjeft, that I have to requeft, when your knowledge in it is compleat- ed, C 5 ) ed, that you would bury my name in filence; and forget that ever I ventured to lay a fingle ftone in this part of the fabric of fcience. In treating upon this fubjedT:, I fhall I. Confider the proper fubjecls and fea- fons for Inoculation. II. I fhall defcribe the method of commu- nicating the diforder. III. I lhall confider the method of prepar- ing the body for the fmall-pox. IV. I lhall mention the treatment proper during the eruptive fever, and V. Point out a few cautions that are ne- ceffary after the difeafe is over. I. Formerly there were great difficulties in the choice of the fubjefts for Inoculation. But experience teaches us that it may be praftifed in every ftage of life, and inalmoft every con- dition of the human body.—In infancy the pe- riods before and after dentition are to be prefer- ed.—But we feldom fee any great inconvenien- cies from fubmiting to the general necefTity of inoculating children between the ages of three months C 6 ) months and two years.—Indeed we often fee children cut three or four teeth during the pre- paration and eruptive fever without the leaft ad- dition being made to any of the troublefome fym- ptoms which accompany the fmall-pox. There is one inconvenience attending the choice of the firft months of infancy for inoculating, and that is the matter often fails of producing the diforder in fuch young fubjedts. I have frequently failed in two or three attempts to communicate the diforder to children under four months old with the fame matter that has fucceeded in a dozen other patients inoculated at the fame time.—When the Inocu- lation fucceeds in fuch tender fubjefts, they ge- nerally have lefs fever, and fewer puftules than are common in any future period of life. Altho' a phyfician would prefer a patient in good health to any other as a fubjedt for Inoculation, yet cafes often occur in which it is necefTary to communicate the fmall-pox while the body is affefted with fome other diforder. I can with pleafure inform you, that the fmall-pox is rendered fo perfe&ly fafe by Inoculation, that there are few chronic difeafes which fhould be confidered as obltacles in the way of it. I have inoculated patients labouring under a tertian C 7 ) fcerdan fever, obftrudted vifcera, the hooping cough, the hypochondriasis, the afthma, the itch, and other cutaneous diforders, and even pregnant women with the fame, and in fome in- ftances, with greater fuccefs than perfons in perfedl health. Dodt. Cullen informs us that he has feen Inoculation fucceed in fcrophulous patients. A phyfician in Jamaica informed me that he had inoculated Negroes with fuccefs in the worft ftage of the Yaws'.—To thefe fadts I muft add one more extraordinary than any that has been yet men- tioned.—Dodt. Brown, my late colleague in the care of the military hofpitals, informed me, that he had feen Inoculation fucceed in patients who were feized, after the ihfedtion was communicated, with the hofpital fever.—The preparation of the body fhould be accommodated to the difeafe which affedts it. Some phyficians have thought the fmall-pox received in this way, was a remedy for other difeafes, but my experience has not confirm- ed this opinion. On the contrary I am difpofed to think that no other change is produced by Inoculation than by the regimen and medicines that are ufed to prepare the body for the fmall- pox. Nor does the fmall-pox during its conti- nuance afford any fecurity againft the attacks of ether difeafes. I have feen the moft alarming com- C 8 ) complication of the fmall-pox and mealies in the fame perfon. The feafons commonly prefered for Inocu- lation in this country are the fpring and fall. It may be pradtifed with equal fafety in the win- ter, a due regard being had to the temperature of the air in the preparation of the body. The principal objedtion to inoculating in the fummer months in this climate, arifes from the frequency of bilious diforders at that fea- fon, to which the preparation necefTary for the fmall-pox probably difpofes the body. This cau-r tion applies more diredtly to children who at a certain age are more fubjedl than grown people to a diforder in their bowels in warm weather. II. The methods of communicating the fmall-pox by Inoculation, have been different in different countries and in the different aeras of its progrefs towards its prefeht, ftage of im- provement. The fcab, doffel of lint, and the thread impregnated with variolous matter and bound up in a gafh, in the arm, have been laid afide. We ( 9 ) We are indebted to Mr. Sutton for the ftode of communicating it by a flight purtdture with the point of a lancet or needle dipt in frefh. matter. As it is difficult fometimes to procure matter in a frefh ftate, I have been led to ufe it with equal fuccefs by preferring it on lint in a box, and moiftning it with cold wate* juft before I ufed it. Matter may be kept in this way for a month without loofing its in- fectious quality, provided it is not expofed to heat or moifture. The former deftroys its power of infedting as certainly as the fait of tartar de- ftroys the acidity of vinegar. Moifture by re- maining long upon the matter, probably deftroys its virulence by fubjedting it to fermentation. The longer matter has been kept in a general way, the longer the diftance will be between the time of communicating the diforder and" the eruptive fever. It will be proper always to yield to the prejudices of our patients in favour of matter taken from perfons who have but few puftules. But I am perfuaded from repeated ob- servations, that the difeafe is no ways influenced by this circumftance. I am fatisfied likewife that there is no difference between the effedts of the matter whether it be taken in its watery or purulent ftate. The pundture mould not be larger than is fufficient to draw one drop of blood* h —No C io ) —No plafter nor bandage fhould be applied over it. It fhould be made in the left arm of all fubjedls. The objedlions to inoculating in the leg are too obvious to be mentioned. I have heard of the difeafe being communicated by rub- bing the dry fkin with the matter. My own obfervations upon this fubjedl give me reafon to fufpedl the fadts that are contained in books re- lative to this mode of infedling the body. I have bound large pieces of lint dipt in frefh matter for 24 hours upon the arm without producing the difqrder. A pradlitioner of phyfic in New-Jer- fey informed me that he once gave a confiderable quantity of frefh variolous matter in a dofe of phyfic without infedling his patient. I fufpedl the matter that produces the difeafe is of the fame nature with certain poifons, which require to be brought in contadl with a wound or fore in the body before they produce their effedls. I deliver this opinion with diffidence. The fubjedl ftands in need of more experiments and investi- gation. III. I come now to confider the beft me- thod of preparing the body for the fmall-pox__ This muft be done ill by Diet, and 2dly by Medicine.—The Diet fhould confift chiefly of vegetables. I have never feen any inconvenience from ( II ) from the free ufe of milk as a part of the pre- parative diet. In fome habits where a morbid acid prevails in the ftomach, we may indulge our patients in a little weak flefh broth two or three times a week with fafety.—Tea, coffee, and even weak chocolate with bifcuit or dry toaft may be ufed as ufual by perfons accuftom- ed to that kind of aliment. Wine and fpirits of all kinds fhould be withheld from our pati- ents during the preparation.—The more acefcent their drinks are, the better. It is unneceflary that this change in the diet fhould take place 'till a day or two before the time of commu- nicating the diforder. The fyftem accommodates to a vegetable and low diet in the courfe of three weeks or a month, fo as to defeat in fome meafure the advantages we expedled from it.— The good effedls of it appear to depend in a great degree upon the fuddennefs with which we oblige our patients to conform to it. For this reafon when we are called upon to inoculate per- fons who have lived more than three or four weeks upon a low diet, we fhould always diredl them to live a few days upon animal food before we communicate the diforder to them. By thefe means we may produce all the good effedls of the fudden change in the diet I have already men- tioned. 2. The Medicines moft commonly ufed to C 12 ) to prepare the body for the fmall-pox are Anti- mony and Mercury. The latter has had tha preference and has been given in large quantities under a notion of its being a fpecific antidote to the variolous matter. Many objections might be made to this opinion, I fhall mention only three. i. We often fee the diforder in a high degree after the fyftem is fully impregnated with mercury. 2. We often fee the fame falutary effedls of mercury when given before the diforder it communicated to the body, that we perceive when it is given after Inoculation in which cafe we are fure the mercury cannot enter into mixture with the variolous matter fo as to de- ftroy it. 3. If mercury adled fpecifically in deftroy- ing the variolous matter, it would render every other part of the preparation unneceffary, but this we know is not the cafe, for the negledl or improper ufe of the vegetable diet or cool regimen is often attended with an extraordinary number, or virulence of the fmall-pox even in thofe cafes where mercury is given in the largeft quantity. The ( 13 ) The way in which mercury prepares the body for the fmall-pox feems to be by promot- ing the feveral excretions, particularly that by perfpiration, which by diminifhing the quantity of the fluids and weakening the tone of the folids, renders the fyftem lefs liable to a plentiful e- ruption of the fmall-pox. But I objedl to the ufe of this medicine for the following reafbns. i. It effedlually deprives us of all the be- nefits of the cool regimen, for mercury we know* always difpofes the fyftem to take cold. a. It fubjedls patients after Inoculation to troublefome and, in fome cafes, dangerous glan- dular fwellings. This will readily be admitted by all who know the tendency mercury has to ftimulate the glandular parts of the body. 3. All the good effedls of mercury may be procured by Purges which do not fubjedl the body to either of the above mentioned incon- veniencies. The Purces may be failed to the confti- tutions, and in fome cafes even to the inclina- tions of our patients. I have feen jalap—rhu- barb—fenna—manna-—aloes—foluble tartar— Glauber and Epfom falts—the butternut pill— all ( H ) all given with equal fuccefs. The quantity fhould be fufficient to procure three or four ftools every day. A little magnefia fhould always be mixed with rhubarb and jalap in preparing children. It will be fufficient for the mothers and nurfes of infants to conform ftridtly to the vegetable diet. I have never feen any advantages from giving them even a fingle dofe of phyfic. It is hardly necefTary to obferve that the quality—dofe—and number of purges are to be determined by the age—fex—and habits of our patients. A conftitution infeebled with a previ- ous difeafe forbids the ufe of purges, and requires medicines of a reftorative kind. Patients afflidled with cutaneous diforders bear larger and more frequent dofes of phyfic than are indicated in more healthy fubjedls. In adult fubjedls of a plethoric habit, blood- letting is very ufeful on the third or fourth day after Inoculation. We are not to fuppofe, that every fat perfon labours under a plethora. A moderate degree of fat is fo far from rendering the difeafe more violent, efpecially in children, that I think I have generally found fuch fubjedls hivQ the fmall-pox more favourably than others. Moderate C is ) Moderate exercife in the open air fhould be ufed during the preparation. But hard labour and every thing that promotes fweat or fatigue as alfo the extremes of heat and cold, fhould be avoided. IV. We come now to confider the treat- ment of the body during the eruptive fever. On the eighth day after Inoculation our pa- tients are generally feized with the .common fym- ptoms of fever. Sometimes this fever appears on the fixth and feventh day after Inoculation. But when it is irregular it is often delayed 'till the ninth and tenth days. I have feen many in- ftances of. it on the fourteenth, a few on the fifteenth and fixteenth, and one cafe in which it did not come on 'till the eighteenth day after the infedlion was communicated to the body.— The place where the pundlure was made with the lancet or needle generally ferves as an har- binger of the approaching fever. A flight in- flammation appears about it and a pock rifes up in the center. But this remark is liable to fome objedlions. I have feen four in-* 'fiances in which the fever came on at kthe ex- pedled time, and the diforder went thro' all its ftages with the greateft regularity, and yet there was C 16 ) was no fign of an inflammation or pock near the fpot where the pundlure was made; even the pundlure itfelf became invifible.—On the 0- ther hand we fometimes fee an inflammation and pock on the arm appear on the eighth and ninth days without any fever accompanying them. Some phyficians pretend that this inflammation and fblitary pock are fufficient to conltitute the difeafe, but repeated experience has taught me to be very cautious in relying upon thefe equivocal marks. It is true, I have fometimes feen patients fecured againft the fmall-pox both in the natural way and by Inoculation where thefe marks have ap- peared ; but I have as often feen fuch patients feized afterwards with the fmall-pox in the natural way to the great diftrefs of families and mortification of phyficians.—Upon this account I make it a conftant pradlice to advife a fecond or third Ino- culation where a fever and eruption have been wanting.—^As the abfence of thefe fyrhptoms is probably occafioned by the weaknefs or age of the variolous matter, or the too high ftate of pre- paration of the body, we fhould always guard a- gainft both, by making the pundlure the fecond time with fri/h matter—by fubjedling our pa- tients to a left abftemious diet* and by giving fewer dofes of phyfic. I have heard it remarked that ( i? ) that if a flight rednefs, and a fmall pimpfe ap* peared on the arm on the third day after Inocula- tion, it was a fign the matter had infeaed the whole conftitution. I acknowledge I have often feen a greater degree of rednefs on the third than on the fecond day after Inoculation, but I have not been able to eftablifh a diagnoftic mark from it, for I have feen the difeafe produced on the ufual days where the rednefs has appeared on the fecond day—and in fome cafes where it has not appeared until the eruptive fever. I am led here unwillingly to difcufs the old queftion, Is it poffible to have the fmall- pox in the hatural way after Inoculation?—In many of the cafes fuppofed to be the fmall-pox from Inoculation, it is probable the matter has been taken from the chicken-pox which refembles the fmall-pox in many of its peculiarities, but in none more than that of leaving pits or marks on the fkin. But there are certainly cafes where there are the moil irrefragable proofs of the in- fedlion implanted by Inoculation being of- a vari- olous nature, where the diforder has been afters wards taken in the natural way. In thefe cafes I would fuppofe the variolous riratter produced on- ly a topical or cuticular diforder. We fee fome- thing analogous to this in nurfes who attend pati- c ents C 18 ) ents in the fmall-pox. But further—this topical or cuticular infedlion may be produced by art in perfons who have had the fmall-pox in the natural way. Some years ago I made a pundlure on my left hand with a lancet moiftened with va- riolous matter. On the eighth day an inflamma- tion appeared on the place accompanied with an efflorefcence in the neighbourhood of it which extended about two inches in every diredlion from the fpot where the pundlure was made. On the nth day I was furprifed to find two pocks (if I may venture to call them fuch) the one on the outfide of my fourth finger on my left hand, and the other on my forehead. They remained there for feveral days but without filling with matter, and then dropped offrather in the form of a foft wart than of a common fcab.—Dodt, Way of Wilmington repeated the fame experi- ment upon himfelf, but with an iflue to his cu- riofity more extraordinary than that I have juft now related. On the eighth day after he had made a pundlure on his hand, a pock appeared on the fpot, which in the ufual time filled with matter, from which he inoculated feveral children, who ficken'd at the ufual time, and went thro' all the common ftages and fymptoms of the fmall-pox— It would feem from thefe fadls that it is necef- fary ( 19 ) . fary the fmall-pox fhould produce fome impref- fion upon the whole fyftem in order to render it ever afterwards incapable of receiving an impref- fion of a fimilar nature. A fever and an erup- tion therefore feem necefTary for this purpofe. As the inflammation of the arm on the eighth day is a fign of the topical and cuticular infedlion, fb an eruption (tho' ever fo fmall) feems to be the only certain fign of the infedlion of the tvhole fyftem. The eruption is the more decifive in its report in proportion as it comes out and goes off in the ufual manner of the fmall-pox in the natural way. In thofe cafes where pati- ents have been fecured againft a fecond attack of the diforder, where there have been no obvious fever or vijible eruption, I think I have obferved an unufual inflammation, and a copious and long continued difcharge of matter from the arm. Perhaps this may ferve as an outlet of the matter, which in other cafes produces the fever and e- ruption. I am the more difpofed to embrace this opinion from the teftimony which feveral authors have left us of the effedls of ulcers in fecuring the body from the infedlion of the plague. The ef- fedls of iflues are ftill more to our purpofe. We obferve a plentiful difcharge of matter from $iem every time the body is expofed to cold, and the ( 20 > the febrile effedls of it upon the fyftem are there- by frequently obviated.—How far a ratio exifts between the degrees of inflammation and the dif- charge of matter from the arm, and the degrees of fever and eruption, mult be determined by future and very accurate obfervations. If it fhould ap- pear that there are the leaft inflammation and, fmalleft difcharge where there have been the bigheft fever and moft copious eruption, and on the contrary, if it fhould appear that there are the greateft inflammation and difcharge where there have been the leaft fever and fmalleft e- ruption, I rnuft beg leave to add without attempt^ ing in this place to explain the reafons of it, that the remark, if generally true, is liable to fome ex- ceptions. But the fubjedl is involved in dark- nefs; I fhall be fatisfied if I have brought you within fight of the promifed land. Your own ingenuity like another Jewifh leader muft condudl you thither. The indications in the treatment of the body during the eruptive fever are I ft To regulate the degree of fever. zd To mitigate troublefome and alarming fymptoms. The C 21 ) The fever which produces the eruption ij generally of the inflammatory kind. It fome- times therefore comes on with the fymptoms of great heat, preceded with chillinefs, determina- tion to the head and breaft, and a full hard pulfe. The remedies proper in this cafe are a. Bloodletting. The quantity to be drawn muft be regulated by the violence of the fym- ptoms,—the conftitution—habits, and even coun- try of the patient, and by the feafon of the year.—I have never found more than one bleed- ing to the quantity of 12 or 14 ounces necef- fary in any ftage or degree of the eruptive fever of the fmall-pox by Inoculation. B. Cool air is of the utmoft confequence in the eruptive fever. The ufe of this remedy in fevers marks an asra not only in the manage- ment of the fmall pox but in medicine. The degrees of cold fhould always be increafed in proportion to the violence of the fever.—Stove- rooms, fo common in this country, fhould be care- fully avoided. The more we ohlige our patients to fet up and walk in the open air the better. Even in thofe cafes where they languifti moft for the bed, they fhould be encouraged rather to lay »pon, than under the bed cloaths.—Children fhould ( 22 ) fhould be ftript of flannel petticoats that come in contadl with their fkins, and even clouts fhould be laid afide if poffible without great inconve- nience, and at any rate they fhould be often re- moved.—Great and obvious as the advantages of cold air are in the eruptive fever, it has fome- times been ufed to an excefs that has done mif- chief.—There are few cafes where a degree of cold below 40 of Farenheit's thermometer is necefTary in this ftage of the fmall-pox. When it has been ufed below this, or where patients have been expofed to a damp atmofphere fome degrees above it, I have heard of inflammations of an alarming nature being produced in the throat and breaft. c. The bowels, more efpecially of children, fhould be kept open with gentle laxatives. And d. Cool fubacid drinks fhould be drank plentifully until the eruption is completed. Sometimes the fmall-pox comes on with a fever the reverfe of that which we have defcribed. The heat is inconfiderable, the pulfe is weak, and fcarcely quicker than ordinary, and the patient com- plains of but flight pains in the back and head. Here the treatment fhould be widely different fron* that C 23 ) that which has been mentioned when the fever is of the inflammatory kind. Bleeding in this cafe is hurtful, and even cool air muft be admit- ted with caution. The bufinefs of the phyfician in this cafe is to excite a gentle adlion in the fangui- ferous fyftem, in order to produce the degree of fever necefTary to the eruption of the pock.— For this purpofe he may recommend the ufe of warm drinks, and even of a warm bed with ad- vantage.—If the eruption delays beyond the third day with all the circumftances of debility that have been mentioned, I have frequently ordered my patients to eat a few ounces of animal food and to drink a glafs or two of wine with the moft defirable fuccefs. The effedls of this indul- gence are moft obvious where the weaknefs of the fever and the delay of the eruption in chil- dren have made it necefTary to allow it to mo- thers and nurfes.— The fmall-pox by Inoculation fo feldom comes on with the fymptoms of a putrid fever, that little need be faid of the treatment proper in fuch cafes. I fhall only obferve, that the cold regimen in the higheft degree pro- mifes more fuccefs in thefe cafes than in any •thers.—I have repeatedly been told, that when the t H ) the fmall-pox appears confluent among the A- fricans, it is a common pradlice for mothers to rub their children all over with pepper, and plunge them immediately afterwards into a fpring of cold water.—This, they fay, deftroys a great part of the pock, and difpofes the remainder to a kind- » ly fuppuratiori. From the fuccefs that has attend- ed the ufe of the cold bath in putrid fevers in fome parts * of Europe mentioned in a former ledture, I am difpofed to believe in the efficacy of the African remedy. The fever generally lafts three days, and the eruption continues for a fimilar length of time, counting the laft day of the fever as the firft day of the eruption. But this remark is liable to marly exceptions. We fometimes obferve the eruption to begin on the firft, and often on the fecond day of the fever, and we fometimes meet with In a diflertation entitled " Epidemia »*•-•;•