NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland . THB NEW METHOD 0 F INOCULATING tOU THE S M A L L-P O X. DELIVERED IN A LECTURE IN THE UNIVERSITY OF PENNSYLVANIA, ON THE 20th OF FEBRUARY, 1781. ft Y BENJAMIN RUSH, M.D. Profeflbr of the Inftitutes and of Clinical Medicine in the Univerfitf of Pennfylvania. THE THIRD EDITION. PHILADELPHIA! in-*d and 301.D by PARRY HALL, no. I4g, «tt»»xwr STRUT, NEAB. SOU*T» JTRSIT, M.DCC.XC1I. 5 [33 o v & THE NEW METHOD Inoculating for the SmalUPox. GENTLEMEN, IT muft afford no fmall pleafure to a benevolent mind in the midft of a war, which daily makes fo much havoc with the human fpecies, to reflect, that the fmall-pox which once proved equally fatal to thoufands, has been checked in its ca- reer, and in a great degree fubdued by the practice of Inoculation, It is foreign to my purpofe to deliver to you the hiftory of this art, and to mark the various fteps that have attended its pro- grefs to its prefent ltate of improvement. We have yet to lament the want of unifor- mity and of equal fuccefs in the practice of it among phyficians. A great number [ 4 ] of pamphlets have been written upon the fubject without exhaufting it. There is frill ample room left for the man of genius to exercife his talents for obfervation and reafoning upon it. The facts I mean to lay before you are fo inconfiderable, com- pared with what ftill remain to be known upon this fubject, that I have to requeft, when your knowledge in it is compleated, 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 fubject, I fhall I. Consider the proper fubjects and feafons for inoculation. II. I shall defcribe the method of communicating the diforder. III. I shall confider the method of preparing the body for the fmall-pox. IV. I shall mention the treatment pro- per during the eruptive fever; and, V. Point out a few cautions that are neceffary after the difeafe is over. I. For- [ S ] I. Formerly there were great difficult ties in the choice of the fubjects for Inocu- lation. But experience teaches us that its may be practifed in every ftage of life, and in almoft every condition of the human body. In infancy the periods before and after dentition are to be preferred. But we feldom fee any great inconveniencies from fubmitting to the general neceflity of inoculating children between the ages of three months and two years. Indeed we often fee children cut three or four teeth during the preparation and eruptive fever, without the leaft addition being made to any of the troublefome fymptoms 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 fubjects. I have frequently failed in two or three attempts to communicate the diforder to children under four months old with the fame mat- ter that has fucceeded in a dozen other pa- tients inoculated at the fame time. When the inoculation fucceeds in fuch tender fub- jects, they generally have lefs fever, and fewer puftules, than are common in any future period of life. Although a phy (Irian would prefer a patient in good health to any other as a fub- [ 6 ] ject for inoculation, yet cafes often occur in which'it is neceffary to communicate the fmall-pox while the body is affected with fome other diforder. I can with pleafure inform you, that the fmall-pox is rendered fo perfectly fafe by inoculation, that there are few chronic difeafes which mould be tonfidered as obftacles in the way of it. I have inoculated patients labouring under a tertian fever, obftructed vifcera, the hoop- ing cough, the hypochondriacs, the afthma, the itch, and other cutaneous diforders, and even pregnant women, with the fame, and in fome inftances, with greater fuccefs than perfons in perfect health. Doctor Cullen informs us that he has feen inoculation fuc- eeed in fcrophulous patients. A phyfician in Jamaica informed me that he had ino- culated Negroes with fuccefs in the worft ftage of the yaws. To thefe facts I muff add one more extraordinary than any that has been yet mentioned : Doctor 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 infection was communi- cated, with the hofpital fever. The pre- paration of the body mould be accommo- dated to the difeafe which affects it. Some phyficians have'thought the fmall-pox, re- ceived in this way, was a remedy for other difeafes, but my experience has not con- firmed [ 7 ] firmed this opinion. On the contrary, I am difpofed to think that no other change is produced by inoculation, than by the re- gimen and medicines that are ufed to pre* pare the body for the fmall-pox. Nor does the fmall-pox, during its continuance, af- ford any fecurity againft the attacks of other difeafes. I have feen the moft alarming complication of the fmall-pox and meafles in the fame perfon. The feafons commonly preferred for inoculation in this country are, the fpring and fall. It may be practifed with equal fafety in the winter, a due regard being had to the temperature of the air in the preparation of the body. The principal objection to inoculating in the fummer months in this climate, arifes from the frequency of bilious diforders at that feafon, to which the preparation ne- ceffary for the fmall-pox probably difpofes the body. This caution applies more di- rectly to children who at a certain age are more fubject than grown people} to a dif- order in their bowels in warm weather. II. The methods of communicating the fmall-pox by inoculation, have been differ- ent in different countries, and in the differ- ent aeras of its progrefs towards its prefent t 8 ] fia^e of improvement. 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 are indebted to Mr. Sutton for the mode of communicating it by a flight punc- ture with the point of a lancet, or needle, dipt in frefh matter. As it is difficult fometimes to procure matter in a frefhftate, I have been led to ufe it with equal fuccefs by preferving it on lint in a box, and moift- ening it with cold water juft before I ufed it. Matter may be kept in this way for a month without lofing its infectious quality, provided it be not expofed to heat or moift- ure. The former deftroys its power of in- fecting as certainly as the fait of tartar de- ftroys the acidity of vinegar. Moifture, by remaining long upon the matter, pro- bably deftroys its virulence by fubjecting it to fermentation. The longer matter ha9 been kept in a general way, the longer the diftance will be between the time of com- municating 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 obfervations, that the difeafe is no ways influenced by this circumftance. I am fatisfied likewife that there is no differ- ence [ 9 ] ence between the effects of the matter, whether it be taken in its watery or puru- lent ftate. The puncture fhould not be larger than is fufficient to draw one drop of blood, but it fhould always be made by a Jharp lancet, for the fudden inflammation and fuppuration, excited by a dull lancet, fometimes throw off the matter foas to pre- vent its infecting the body*. No plafter or bandage fhould be applied over the puncture. It fhould be made in the left arm of all fubjects. The objections to inoculating in the leg are too obvious to be mentioned. I have heard of the difeafe be- ing communicated by rubbing the dry fkin with the matter. My own obfervations upon this fubject give me reafon to fufpect the facts that are contained in books rela- tive to this mode of infecting the body. I have bound large pieces of lint dipt in frefh matter for twenty-four hours upon the arm, without producing the diforder. A practitioner of phyfic in New-Jerfey in- formed me that he once gave a confiderable quantity of frefh variolous matter in a dofe of phyfic without infecting his patient. I fufpect the matter that produces the difeafe is of the fame nature with certain poifons, b which * 1 am difpofed to believe that the extern?! applications which are ufed by the Indians for the cure of the bite of poilbnous fnakeS, ad only by ex- citing inflammation and fuppuration, which difcharge the poifon from the wound before it is abforbed. All their external remedies are af'ajtimt<1/iring nature. [ io ] which require to be brought in contact with a wound or fore in the body before they produce their effects. I deliver this opi- nion with diffidence. The fubject ftands in need of more experiments and invefti- gation. III. I come now to confider the belt method of preparing the body for the fmall- pox. This muft be done, ift by diet, and 2dly by medicine. The diet fliould confift chiefly of vegetables. I have never feen any inconvenience from the free ufe of milk as a part of the preparative diet. In fome habits, where a morbid acid pre- vails in the ftomach, we may indulge our patients in a little weak flefh broth two or three times a week with fafety. Tea, cof- fee, and even weak chocolate, with bifcuit or dry toaft, may be ufed as ufual, by per- fons accuftomed to that kind of aliment. Wine and fpirits of all kinds fhould be withheld from our patients during the pre- paration. The more acefcent their drinks are, the better. It is unneceffary that this change in the diet fliould take place till a day or two before the time of communicat- ing the diforder. The fyftem accommo- dates 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 expected from it. The good effects of it appear i 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-r fons who have lived more than three or four weeks upon a low diet, we fhould always direct 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 effects of the fudden change in the diet I have already mentioned. 2. The medicines moft commonly ufed to pre- pare the body for the fmall-pox are anti- mony and mercury. The latter has had the preference, and has been given in large quantities under a notion of its being a fpe- cific antidote to the variolous matter. Ma- ny objections might be made to this opiniT on ; I fhall mention only three. i. We often fee the diforder in a high degree after the fyftem is fully impregnat- ed with mercury. 2. We often fee the fame falutary effects of mercury when given before the diforder is communicated to the body, that we per- ceive when it is given after inoculation ; in which cafe we are fure the mercury can- not enter into mixture with the variolous matter fo as to deftroy it. 3- If t 1a ] 3. If mercury acted fpecifically in de- ftroying the variolous matter, it would ren- der every other part of the preparation un- neceffary, but this we know is not the cafe, for the neglect or improper ufe of the ve- getable diet or cool regimen is often attend- ed with an extraordinary number, or viru- lence of the fmall-pox, even in thofe cafes where mercury is given in the largeft quantity. The way in which mercury prepares the body for the fmall-pox, feems to be by pro- moting the feveral excretions, particularly that by perfpiration, which, by diminifh- ing the quantity of the fluids and weaken- ing the tone of the folids, renders the fyftem lefs liable to a plentiful eruption of the fmall-pox. But I object to the ufe of this medicine for the following reafons: 1. It effectually deprives us of all the benefits of the cool regimen ,• for mercury, we know, always difpofes the fyftem to take cold. 2. All the good effects of mercury may be produced by purges, which do not fubject the body to the above-mentioned inconvenience. The t «3 ] The purges may be fuited to the con- stitutions, and in fome cafes, even to the inclinations of our patients. I have feen jalap, rhubarb, fenna, manna, aloes, folu- ble tartar, glauber and epfom falts, and the butternut pill, 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 ftrictly to the vegetable diet. I have never feen any ad- vantages from giving them even a fingle dofe of phyfic, It is hardly neceffary 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 enfeebled with a previous difeafe forbids the ufe of purges, and requires medicines of a refto- rative kind, Patients afflicted with cutane- ous diforders bear larger and more frequent dofes of phyfic than are indicated in more healthy fubjects, In adult fubjects 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 [ '4 ] fat is fo far from rendering the difeafe more violent, efpecially in children, that I think I have generally found fuch fubjects have the fmall-pox more favourably than others. 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 toconfider 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 fymptoms 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 inftancqs of it on the fourteenth, a few on the fifteenth and fix- teenth, and one cafe in which it did not come on till the eighteenth day after the infection was communicated to the body*. The place where the puncture was. made with the lancet, or needle, generally ferves as an harbinger of the approaching fever. A flight * Since the publication of the firft edition of this,letlure, I have heard of two cafes, in one of whi^h the (ever did not come on till the twentieth, and in the other till the rwenty-firft day after the infeclion was communi- cated ty the 'jo Jy. In fome of thefe tedious cafes, I have feen an inflam- mation and fuppuration on the pun&ured part of the arm on the eighth day without any fever. Perhaps in thefe cafes the inflammation and fuppurati- on are only cutic'ular, and that the fmall-pox is taken from the matter which is formed by them. [ 15 ] A flight inflammation appears about it, and a pock rifes up in the centre. But this re- mark is liable to fome objections. I have Teen four inftances in which the fever came on at the expected time, and the diforder went through all its ftages with the greateft regularity, and yet there was no fign of an inflammation or pock near the fpot where the puncture was made : even the puncture itfelf became invifible. On the other 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 inflam- mation and folitary pock are fufficient to conftitute the difeafe; but repeated expe- rience 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 appeared ; 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 practice to advife a fecond or^ third inoculation where a fever and eruption have been wanting. As the abfence of thefe fymptoms is probably occafioned by the weaknefs or age of the variolous mat- ter, or the too high ftate of preparation of t 16 ] the body, we fhould always guard againft both, by making the puncture the fecond time with frefh matter, by fubjecting our patients to a lefs abftemious diet, and by giving fewer dofes of phyfic. I have heard it remarked, that if a flight rednefs and a fmall pimple appeared on the arm on the third day after inoculation, it was a fign the matter had infected the whole confti- tution. 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 eftabliih a diagnoftic mark from it; for I have feen the difeafe produced on the ufual days where the red- nefs 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 poflible to have the fmall-pox in the natural way after inocula- tion ?—In many of the cafes fuppofed to be the fmall-pox from inoculation, it is pro- bable the matter has been taken from the chicken-pox, which refembles the fmall- pox in many of its peculiarities, but in hone more than that of leaving pits or marks on the fkin. But there are certainly cafes where there are the moft irrefragible proofs of the infection implanted by inoculation being of a variolous nature, where the dif- order [ i'7 1 ordetf has been afterwards taken in the na- tural way. In thefe cafes I would fuppofe the variolous matter produced only a topical or cuticular diforder. We fee fomething analogous to this in riurfes who attend pa- tients in the fmall-pox'. But further, this topical or cuticular infection may be pro- duced by art in perfons who have had the fmall-pox in the natural way. Some years ago I made a puncture on my left hand with a lancet moiftened with variolous mat- ter. On the eighth day an inflammation appeared on the place, accompanied with an.efflorefcence in the neighbourhood of it, which extended about two inches in every direction .from'the- fpot where the puncture was made. On the eleventh day I was fur- prifed to find two pocks (if I may venture to:call them fuch) the one on the outfide of the fourth finger of my left hand, and the ofcher on my forehead. They remained there for1 feveral days, but without filling with matter, and then dropped off rather' in the form of a foft wart than of a common icab.: Doctor Way, of Wilmington, repeat- ed-the fame experiment upon himfelf, but vvith an iffue to his curiofity more extraor- dinary1 tMrP that I have juft now related. On-the eighth day after he had made a puncture oft his hand, a pock appeared on the^ fpbt', which in the ufual time filled'with matter,' from which he inoculated feverar c children, [ 18 ] children, who fickened at the ufual time, and went through all the common ftages and fymptoms of the fmall-pox. It would feem from thefe facts, that it is neceffary the fmall-pox fhould produce fome impref- fion upon the whole fyftem, in order to ren- der it ever afterwards incapable of receiving an impreflion of a fimilar nature. A fever and an eruption therefore feem neceffary for this purpofe* As the inflammation of the arm on the eighth day is a fign of the to- pical and cuticular infection, fo an eruption (though ever fo fmall) feems to be the on- ly certain fign of the infection of the whole 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 patients have been fecured againft a fecond attack of the diforder, where there have been no obvious fever or vifible 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 eruption. I am the more difpofed to embrace this opinion from the teftimony which feyeral authors have left us of the effects of ulcers in fecuring the body from the infection of the plague. The effects of iffues are ftill more to our purpofe. [ >9 1 purpofe. We obferve a plentiful difcharge of matter from them every time the body is expofed to cold, and the febrile effects of it upon the fyftem are thereby frequent* \y obviated. How far a ratio exifts be- tween the degrees of inflammation and the difcharge of matter from the arm, and the degrees of fever,and eruption, muft be de- termined by future and very accurate obfer- vations. If it fhould appear that there are the leaft inflammation and fmalleft dif- charge, where there have been the higheft 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 eruption, I muft beg leave to add, without attempting in this place to explain the reafons of it, that the remark, if gene- rally true, is liable to fome exceptions. But the fubject is involved in darknefs; I fhall.be fatisfied if I have brought you with-, in fight of the promifed land. Your own ingenuity, like another Jewifh leader, muft conduct 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 [ 2° 1 2d. To mitigate troublefome and alarm-. ing fymptoms. The fever which produces the eruption. is generally of the inflammatory kind. It fometimes therefore comes on with the fymptoms of great heat, preceded with chil- linefs, and determination to the head and breaft, and a full hard pulfe. The reme-, dies proper in this cafe are, £. Blood-letting. The quantity to be drawn muft be regulated by the vio- lence of the fymptoms, the conftitufion, habits, and even country of the patient, and JDy the feafon of the year. I have never found more than one bleeding, to the quan- tity of twelve or fourteen ounces, neceffary in any ftage or degree of the eruptive feyer of the fmall-pox by inoculation. B. C o o l air is of the utmoft confequencc in the eruptive fever. The ufe of this rer medy in fevers marks an aera, not only in the management of the fmall-pox, but in medicine. The degrees of cold fhould al- ways be increafed in proportion to the vio- lence of the fever. Stove-rooms, fo. con>r mon in this country, fhould be carefully avoided. The more we oblige our patients to fet up and walk in: the open air, the bet- ter. I ™ 3 ter. Even in thofe caies where they fan- guifh rnoft for the bed, they fhould be en- couraged rather to lie upon, than under the bed-clothes. Children fhould be ftriptof flannel petticoats that come in contact with their fkins ; and even clouts fhould be laid afide if poffible, without great inconveni- ence, and at any rate they fliould be often removed. Great and obvious as the ad- vantages of cold air appear to be in the eruptive fever, it has fometimes been ufed to an excefs that has done mifchief. There are few cafes where a degree of cold below forty of Fahrenheit's thermometer is necef- fary in this ftage of the fmall-pox. When jt has been ufed below this, or where pa- tients have been expofed to a damp atmof- phere fome degrees above it, I have heard of inflammations of an alarming nature be- ing produced in the throat and breaft. c. The bowels, more efpecially of chil- dren, fhould be kept open with gentle lax- atives. And d. Cool fubacid drinks fhould be ufed plentifully until the eruption is compleated. Sometimes the fmall-pox comes on with a fever the reverfe of that which we have defcribed. The heat is inconfider- able„ the pulfe is weak, and fcarcely quick- er [ -1 ] tr than ordinary, and the patient complains of but flight pains in the back and head. Here the treatment fhould be widely dif- ferent from that which has been mention- ed when the fever is of the inflammatory kind. Bleeding: in this ca!e is hurtful, 'P . .. and even cool air muft be admitted with caution. The bufinefs of the phyfician in this cafe is to excite a gentle action in the fanguiferous fyftem, in order to pro- duce the degree of fever which is neceffary to the eruption of the pock. For this purpofe he may recommend the ufe of warm drinks, and even of a warm bed, with advantage. If the eruption delays beyond the third day, with all the circum- ftances of debility that have been mention- ed, 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 effects of this indulgence are moft obvious where the weaknefs of the fever and the delay of the eruption in children, have made it neceffary to allow it to mothers and nurfes. The fmall-pox by inoculation fo feldonr comes on with the fymptoms of a putrid fever, that little need be fiid of the treat- nent proper in fuch cafes. I fhall only cb:\rve, that the cold rcginrw-n in the high- eft degree, promifes more fuccefs in thefe cafes t 23 ] cafes than in any others. I have repeated- ly been told, that when the fmall-pox ap- pears confluent among the Africans, it is a common practice 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 re- mainder to a kindly fuppuration. From the fuccefs that has attended the ufe of the cold bath in putrid fevers in fome parts* of Europe, mentioned in a former lecture, 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 thelaft day of the fever as the firft day of the eruption. But this remark is liable to many exceptions. We fometimes obferye the eruption to begin on the firft, and often on the fecond day of the fever ; and we fometimes meet with cafes in which a fecond eruption comes on after the fever has abated for feveral days, and the firft eruption confiderably advanced in its progrefs towards a com- plete ' * In a differtation entitled " Efldemla -verna qute JViatiJlawam, A/mo '737 afflixii," puhlifned in the appendix to the Afta Nat. Curios. Vol. X. it appears, that warning the body all over with coid water in putrid fe- vers, attended with great debility, was attended with fuctefs at Bit/Ia-M in SiUJtet. The practice has fince been adopted, we are told, by feveral of the . neighbouring countries. Cull en's fi&st lines of The prac- tice OF PHY SI C. E *4 1 plete fuppuration. This is* often oe~