New Observations on Inoculation

Front matter

NEW

OBSERVATIONS

ON

Preliminary discourse

A

Preliminary Discourse

Containing

A short Account of the present State of Inoculation in France.

I Received this little tract from the author, towards the beginning of last spring, when I was confined to my bed by a severe fit of illness. The reasonable relief which it gave to my mind, induced me to employ my sleepless hours in translating it; and I thought my labour not ill bestowed, if it could afford any entertainment or instruction to English readers.

Whether this piece will be received as well as my ingenious friend Mr. de la Condamine's Discourse on Inoculation, I shall not pretend to determine. To me they appear equally valuablel and the singularity of the present work may recommend it to a people, amongst whom those writers are peculiarly held in esteem, who thinking for themselves dare to print what they think.

In another country, indeed not his own, Dr. Gatti suffered for his boldness. Upon the recommendation of a French lady of distinction, whose son he had most happily inocu , he was invited over to the court of France. The minister thought him a proper person to establish the practice in that kingdom; and the inhabitants were supposed inclined to receive it from any quarter rather than from a nation at that time engaged in war with them.

Our Italian physician had, like his countryman Pylarini, learned the art of inoculating in the Levant. There he had seen the operation in its primitive dress, performed by Greek women, and recommended by Greek priests. The hand of surgeons was unemployed, the pen of physicians not desired. A needle was the sole instrument; a little matter imbibed in cotton, or dried in powder, the only apparatus. No accidents were known to happen; no troublesome ulcer or disorder to succeed. A gentle fever, during four-and-twenty-hours, was the only symptom; and a small crop of pustules, chiefly upon the part where the pock was rubbed in, without ruffling, lowering, or endangering the patient, secured his life, his organs, and his features.

To great sagacity my friend joined an open and beneficent mind. What he had seen, he proclaimed every where. He was in hopes that a people equally fond of novelty and ease, would readily adopt this new and elegant mode. The great, and especially their leaders, the ladies, he imagined, would be allured by being put to no fright and no pain, unre in their diet, undisturbed in their joys; the people would be drawn in by an operation either chargeable nor confining; all would be glad to enjoy the benefits of inoculation without its risks, and to spread it new fashioned all over the continent:

That eloquence of heart, which never fails to please, and seldom to convince, gave our professor great advantages over his rivals. In defiance of vulgar opinion and physical authority, he attempted to change an operose process into a mere amusement. Dr. Tronchin had had his short, his brilliant day, and Dr. Hosty, instructed in London, inoculated with care, and slowly made some converts. Italian was more prevailing than either. Every body would be inoculated by Gatti; and while he himself declared that any nurse could do well as he, the public imagined nothing well done without him.

This uncommon success soon excited envy. Those, whose trade he obstructed, became enemies. Rumours were propagated, and scruples were infused. To some it was said that he gave not the small-pox; to others, that his patients would carry it every where. The churches and play-houses were now no longer safe, whispered the delicate Abbe; and the still more insinuating doctor, shrugging his shoulders at the toilet, exclaimed against public infatuation.

Perhaps this might have been avoided, if Dr. Gatti had been more reserved, and obser of forms. A dutchess, whom he had inoculated, and who, upon equivocal symptoms without any eruption, had been declared secure against future infection, after three years caught the natural disorder, which, though not hurtful to her, became fatal to him. He displayed the utmost candor in publishing the case; but could by no means recover what he had lost, the support of the great, the confidence of the town. All his former patients took the alarm; he became the object of public abuse, as he had formerly been of general applause; and that salutary practice, which he had endeavoured to render popular, by making it more easy and more safe, fell as it had risen with him.

Indeed, it had already received a severe blow; The discouragement it met with from some eminent physicians, the impetuous attacks of a justly celebrated professor at Vienna and above all, the religious scruples of a Saxon princess, influenced the parliament of France, then, and almost ever, at variance with the court. Upon the representations of the attorney-general, they thought proper to prohibit inoculation in the capital; and having thus prejudged the cause, gave orders to the faculties of divinity and physic to make inquiries into the merits of it.

The physicians took the lead, and doubtless with good reason, as the legality of the thing must ultimately depend upon its usefulness. The college, a numerous body, consisting of above one hundred and twenty doctors, appointed twelve commissaries, to make new researches, and prepare a report, upon this interesting subject. This committee, composed of the leaders of both parties, agreed upon five queries to be sent all over Europe, in order to obtain new lights, and render, if possible, their judgment decisive and SIC|unamimous|unanimous.

This, however, was not the case; for, though the answers which came, at least from those who were really qualified to give any, were greatly in favour of inoculation, an equal division of opinions still took place amongst the members of the committee; six declared against, and six for, the English practice. The former were the first in giving and publishing their report. This libel, for it deserves no other name, written with great art and no less disingenuousness, contains, besides the old and exploded objections of Wagstaff, Blackmore, Cantwell, and De Haen, a number of facts collected both in France and in Great Britain. The book no sooner appeared, but the most material of these facts, said to have happened in the first of these kingdoms, were publickly contradicted, and proved to be mistakes; and it would be no difficult task to do the same, with respect to most of those sent over from this island, were this a proper place for such a discussion.

Later, but not less keen, were the favourers of inoculation in their answer. The col were induced by this last report, to declare, by a great majority of votes, that inoculation deserved to be tolerated. The parliament, however have hitherto not recalled their first order; the practice remains under the same unnatural interdiction; and it is only out of the walls of Paris, and especially in the provinces, that the people are suffered to save their lives in their own way.

Both to reclaim the thinking part of Paris, and to vindicate his own operations from the contemptuous treatment of his antagonists, Dr. Gatti, at my request, published the present Essay. Uncertain of its effect upon that lively and volatile nation, who received inoculation upon trust, and upon trust rejected it, he was desirous, by this translation of his work, to appeal to their neighbours, in hopes that, if they approve, his method will in time get the better of prejudice and clamour.

Indeed the English have already decided in his favour. Inoculation is very near universally, in this island, what he wished it in France. The choice of the matter, the manner of the operation, the simplicity of the treatment, the attention to amusements, and the injunction of exercise, are so many points, in which his practice coincides with that which is here generally recommended.

Had Dr. Dimsdale's performance (in which this doctrine, for some time industriously concealed by interested operators, was first brough to light) preceded the discourse of Dr. Gatti, or could the one have borrowed from the other, I should not have taken the trouble of translating that of my Italian friend But his piece was prior; and in a former treatise printed three years ago, the same principles were already, though explicitly, contained.

But still it may, I know it will, be said, that nothing was to be found here but what we knew before, the Public might have dispensed with this publication, as well as with three-fourths of the many ephemerous pamphlets on the same subject, which this insect-producing summer brought forth. I can only answer, that the different way of considering the same objects, the closeness of the method, and the strength of reasoning, which distinguish the author's manner; the extensiveness of his views and the novelty of his hints, were my motives for publishing his Essay in English. May I add, that I was besides animated by the desire of doing justice to an amiable character cruelly misrepresented, and not in France only injuriously traduced?

In one article, however, he differs from modern, as well as ancient, inoculators. He opposes what they recommend, a formal preparation. Yet, as the mode of this preparation remains still unsettled, and where required, must vary according to the difference of constitutions; and as quicksilver and antimony, so much commended, and so indiscriminately given, by some, are not less warmly condemned, or at least slighted, by others, our author may perhaps trust his apology with the ingenious writer thereof the Trial of Mr. Daniel Sutton, for the high crime of preserving the lives of his majesty's liege subjects, by means of inoculation. He only exclaims against empiric or other medicines, when the subject is in full health; and expresly avers that, if he is not well, his cure ought to precede inoculation.

I am well aware that some other notions of Dr. Gatti may be objected to; but they seem to be of little importance to, and not intimately connected with, the main subject. Hypotheses, I know, are almost universally exploded; but few are the men, who do not except their own from this proscription. It is a matter of some difficulty to destroy old theories, without substituting new ones; to tread upon inchanted ground, and not be tempted to build, and to indulge and leave to posterity no visions of our own.

In translating this work, I allowed myself the liberty of abridging it in some parts, of supplying some things from the preceding treatise of our author referred to by himself, and of adding a few notes. In doing this, I had the advice of some of Dr. Gatti's friends, together with his leave; I followed my own taste, and hope to obtain the approbation of those who may compare the original with this copy.

Introduction

NEW

OBSERVATIONS

ON THE

Practice of INOCULATION.

INTRODUCTION.

MANY books have been published within half a century, about inoculation; the authors of which, being mostly intent upon proving the benefits of the method, and paying no attention to the improvement of it, have neglected to determine and direct the best way of giving and treating the disorder communicated in this manner.

The rules laid down by the first introducers of the operation in Europe, have been exactly repeated; the way of inoculating taught in books remains what it was fifty years ago; and every where we find nearly the same directions with regard to the preparation, the manner of inserting the variolous matter, and the treatment of the artificial small-pox. I say the same, for it seems of no great consequence, whether the preparation is a little more or less rigorous; the insertion effected by an incision or a blister; the incision somewhat slighter or deeper; whether it is made in the legs or arms; whether the matter is used alone, or dried and powdered, or imbibed in a thread; and lastly, whether the purging is more or less repeated: these differences are too inconsiderable to make any essential distinction between the methods hitherto taught, or to occasion much variety in the success.

The apology of inoculation ought, however, to be attended with, if not preceded by, researches on the best method of inoculating: for if it is a salutary practice, when carried on in a certain way, but becomes fatal to many patients when differently managed, this defence will not be properly supported, unless the particular mode of the operation is previously determined and exactly pointed out.

From the inattention of those who have written upon the subject, might it not be concluded, that there really is but one method of inoculating; or if more, that they are equally good? that, provided the variolous matter be inserted, and the small-pox conveyed, all the rest is of no consequence; and if the operation should be more or less successful, or even if fa accidents should happen after it, that these effects are to be imputed to nature, to chance, to inoculation itself, but by no means to the particular method which has been followed?

Superficial observations may seem to strengthen this opinion. In looking over the accounts of inoculations performed in different times and countries, it appears, that much the same method has been pursued, both in happy and unfortunate cases; and even that the rules prescibed have been more closely attended to in the latter than in the former.

There is, nevertheless, a safe way of inoculating, and there are improper methods. By the one the disorder is attended with no danger while it lasts, nor any bad consequences when it is over. By the other, the patient is either exposed to a real danger, and a grievous illness, or may apprehend bad, and sometimes lasting, consequences after the termination of the disorder. There is a method by which thousands may be inoculated without the Ioss of any; and there are modes of acting by which the proportion, between those who die and those who escape, is considerable enough to startle the fond parent with regard to his children, and the courageous man with regard to himself.

The following facts will prove this assertion. In the little town of Blandford, 384 persons were inoculated; of whom thirteen died, a great number laboured under a confluent small , and several were in the utmost danger of their lives.

In the course of the two last years, upwards of 9000 persons have been inoculated in Essex, without the loss of a single life, or the appearance of any accident.

I have made choice of these two facts, because they lay before us at one view a great number of inoculations. They are recent; and happened in a state where all disputes about the utility of the method itself are at an end and consequently where truth has nothing more to fear from party-spirit.

Were we to pass a judgment from these two facts, on the supposition that in both cases the method was the same, and the difference in the success the mere effect of chance, we should be apt to conclude, that what has been said for and against inoculation is equally true. It is a salutary practice; it is a murderous scheme; and in this opposition of facts, the wife man might remain in suspence.

But if the methods were not the same, the two propositions ought to be altered into these: inoculation, when managed in a certain manner, may be dangerous; but if managed in another way, it is useful and salutary.

This last conclusion will be admitted by every unprejudiced mind. If the Essex people were inoculated differently from those of Blandford, as in fact they were, we shall be able to assert, that the former were inoculated in a proper, and the latter in an improper, manner; and consequently, that there is a right as well as a wrong method of inoculating.

The history of this practice will hardly furnish any other instance of so great an inequality; but a number of facts may be found differing enough to warrant the same inference; and my own experience would have led me to the same conclusion.

I have attended above a thousand inoculations, either performed by other people, or managed by myself; I have tried every known method; the rules prescribed have sometimes been observed, and sometimes neglected by me. By singular good luck, I have lost not one patient; but all the other accidents imputed to inoculation have fallen under my inspection.

Some have had a confluent small-pox, and been in danger; others have suffered, besides the small-pox, an additional infectious disorder. Many have had troublesome complaints after the operation; wounds not easily healed, erysipetalous tumours, abscesses, imposthumes; and lastly, some thinking themselves safe after having gone through what was thought inoculation, have since caught the distemper in the natural way.

Notwithstanding these inconveniences, I have continued recommending and practising inoculation, both because they are far less considerable than those which attend the chance of the natural small-pox, and because the worst of these mischances happened to me more rarely than to most other inoculators.

I now think, I have discovered the cause of all these accidents. Had I from the first made choice of the best method, every one of my patients would have had a true small-pox, both slight and kind, and attended with no bad symptoms, adventitious disorders, or consequential complaints. I was misled by the rules generally laid down; and an opposite way of acting would always have conducted me safely, as in fact it did, whenever I kept to it.

The following tract is the result both of my experiments and of my reflections. My design is not to apologize for inoculation, but to enquire into the best method of managing it.

I write for gentlemen of the profession, and especially for such as have acquired some expe in the art of inoculating. They alone are capable of forming a true judgment and estimation of my assertions, and can induce the public to adopt my practice. In medical matters, the generality of mankind think not from themselves, but from physicians; and the method which I propose will not be regarded, unless authorized and adopted by them.

But how can I hope for their approbation? My notions seem totally different from those which are commonly received; my rules directly opposite to those which have hitherto been laid down; and, in one word, my aim is to prove that we should think the contrary of what has been thought, and do the reverse of what has been done.

Ever since inoculation has been received in Europe, the practitioners have been of opinion that the essential advantages of the artificial over the natural small-pox were, 1. the preparation; 2. the discharge of the variolous matter by means of the wounds; and 3. the assistance of art in a disorder which is known as soon as it appears.

In opposition to these principles, I shall attempt to prove, that these three pretended advantages have hitherto been so many bars to the perfection of the method, and the source of almost all the miscarriages which have retarded its establishment.

All inoculators have said, prepare your subjects; procure an outlet to the venom; be at to administer every help of art, when the disorder shews itself.

I, on the contrary, say, prepare not at all; think of no outlets; and when the disorder comes, trust to nature.

These propositions I purposely premise, that the reader, startled at their seeming absurdity, may the more attentively examine what I have to offer to support them.

Though I should be right, I hardly expert that all operators will, at least for a long while come into my way of thinking. But I entertain better hopes from those physicians, whom knowledge and virtue place above prejudice, trust to time, which sooner or later silences passion, and gets the better of prepossession; and should I be disappointed, I flatter myself to find a sufficient reward in the testimony of my conscience, that I have always fought the good of mankind, and laboured for the discovery of truth.

The doctrine which I endeavour to demonstrate is so plain, that I might have brought it within the compass of a few pages; but it is necessary to explain it, and to establish it upon proofs, in order to remove the prejudices still entertained by many people.

All I have to say will be reduced to three heads. The first regards the preparation; the second, the insertion; the last, the treatment of the disorder. I intend, as much as possible, to forbear any enquiry which does not directly tend to my object, viz. the best method of inoculating.

Chapter I

CHAP. I.

On Preparation

PREPARING a subject for inoculation is endeavouring to give him such dispositions, as it is thought will fit him to go through the small-pox, with as little prejudice to his health as possible.

These dispositions, thus intended to be procured, are understood to be relative to the small-pox, and so peculiar to that disorder, as not to be preparatory to any other.

The preparation, by which these particular dispositions are to be procured, should therefore be particularly adapted to the disorder which is expected. It ought to be founded upon some known analogy between certain dispositions of the animal œconomy and the effects of the variolous virus upon the said œconomy; or at least upon an experimental knowledge, that such or such dispositions are always productive of a slight and mild small-pox.

It follows from this explanation, that, in order to prepare for inoculation with any degree of certainty, we should be acquainted with some dispositions in the animal œconomy distinct from a general state of health, and particularly relative to the small-pox; such as, on the supposition of two subjects enjoying an equal share of health, and every circumstance being in other respects the same in both, he who has those particular dispositions should constantly, or mostly so at least, have a mild and safe smallpox; and he, who has the contrary dispositions, should have it dangerously, and often mortally.

To illustrate this: suppose it had been constantly observed that lean people had fewer and kinder small-pox than fat ones; these last might be prepared for inoculation, by lessening their fat, and reducing them by means of a strict diet to a state of leanness. It is, however, plain that, in order to attempt such a preparation, it must have been demonstrated from repeated experiments, that leanness is a favourable disposition for receiving the small pox with as little detriment as possible to health.

But if no observation has discovered that such or such disposition is more favourable than the contrary one to have the small-pox in the most harmless manner; if the observations made for 1100 years upon the natural, and for upwards of fifty upon the inoculated small-pox, leave us in that respect under the greatest uncertainty; what are we to think of preparations intended to procure particular dispositions, which no body knows with certainty to be more favourable than the contrary ones? Now this is by no means a supposition, but a fact, which every ingenuous physician will readily agree to.

We see this disorder severe or slight, dangerous or harmless, indiscriminately in strong or weak, lean or fat people; in constitutions called hot, or in those which are said to be cold; in dry and in moist habits; in bilious and in phlegmatic subjects. Let us but examine impartially the observations, which have been transmitted to us upon this distemper, let us recollect the small-pox we have seen, whether natural or artificial, and we shall be obliged to confess that the constitutional dispositions, on which the mildness of the disorder depends, are to us entirely unknown, either because they have not been observed, or are beyond the power of observation.

Hence I think myself entitled to conclude, that there is no disposition, at least known to us, particularly relative to the small-pox, and enabling a subject to receive it in that manner, which is least detrimental; and consequently that there is no such thing as preparation for inoculation, in the sense we have affixed to that word.

But if we are ignorant of any particular disposition, we are certainly acquainted with a general one, which is absolutely requisite towards going through the small-pox with as little danger as possible; and that disposition is health itself. The venom applied, and the disorder consequent upon this application, are attacks upon health; and the hurt must be greater or less, as the constitution is weaker or stronger. Experience has shewn, that this disposition is always attended with a kind small-pox, provided other causes, or some error in the insertion or treatment of it do not increase the disorder, and disturb nature in her opera . Health therefore is all we want in subject intended for inoculation.

Granting this, it is evident that there is no need of preparation for a person in full health; and that for one who is not well, the only preparation must be to make him so.

The art of preparing for inoculation is, therefore, no other than the art of curing; and the rules which might be given for the one, are the same which the art of healing prescribes for the other. But to cure a sick person, or to defer giving him the small-pox till he is well, is not properly preparing him for inoculation; on the contrary, it may fairly be said that no intended patient wants any preparation. If he is well, inoculate him; if he is ill, cure him as you would in any other case.

All previous preparation relative and peculiar to inoculation is not only needless, but dangerous, on account of the mischief which may be done, by altering the state of a person in health.

But to remove all doubt, it may not be amiss to answer some objections, which might be started, and which contain the most plausible arguments which have, or might have been, urged in favour of a particular preparation.

First Objection. "Granting that health is the only requisite in your intended patient, you must allow that what is called so admits of great latitude. Many degrees may be conceived from strong to weak health, and from thence down to sickness. A man in the most perfect state is an imaginary being; and between compleat health and the privation of it, or sickness there are numberless middle states, in each of which a man may be said to be well. Therefore, though he is so, some preparation may be proper, if not absolutely necessary, to mend his constitution, and bring it as near as possible to the most perfect state."

Answer. The care of our health ought, at all times, to be attended to; it is the chief of all blessings. Preparation is extremely useful in that view; it is even necessary for those, who, from their duties in life, the pursuit of pleasure, or other circumstances, are apt to live so as to injure their health; and on such an occasion as inoculation, it behoves them to be more particularly careful than they can well be in the common course of life.

Preparation, thus explained, implies a closer attention to avoid whatever might be detrimental; it is negative, consisting of privations not remedies; and as those privations only relate to excesses of any kind, such as labour eating, drinking, &c. it is plain that this is no particular preparation, according to our former definition.

We often see people enjoy excellent health, though living in a different or quite opposite manner with regard to their diet, exercise, or, in short, to what physicians call the six non-naturals. We see, on the other hand, that they are not well, whenever they attempt to change their way of living for that of another. Custom, which is a second nature, can never be altered without danger, even in trifling things, though the change be from worse to better. If any alteration was to be made in a healthy man's way of living, under the notion of improving his health, this ought to be tried at any other time rather than at the eve of inoculation. The good expected is uncertain; the ill that may ensue, though at another time of no great consequence, might at this prove very pernicious.

Were it even certain that any change or positive preparation, would be attended with an encrease of health, still this advantage ought to be balanced with the hazard arising from the dread which this previous process often occasions; and of what consequence this may be, will appear in the sequel of this work.

If, after a serious perusal of these considerations, any inoculator will attempt to give rules for a health-encreasing preparation; if he chuses to prescribe a diet, or to order medicines; his preparation will probably bring on a more considerable disorder than would otherwise have appeared; and some of his patients will deserve the epitaph,

Stavo bene; Ma per volere star meglio Sto qui.

Second Objection. "The idea of health is a complicated one. Two persons equally healthy may have very different constitutions. The small-pox is an inflammatory disorder; and the more a constitution inclines to inflammation, the more dangerous the distemper will prove. Thus a stout and sanguine man, as healthy at least as a weakly or delicate one, shall have a more severe and dangerous small-pox. This tendency towards inflammation must therefore be lessened; preparation is necessary for that purpose, and cannot be dispensed with without rashness."

Answer. 1st. The small-pox is not absolutely an inflammatory disorder. Inflammation, which constitutes the essence of some disorders, in this is only a symptom; indeed, a necessary one, since there can be no pustules without it. 2. Granting that the small-pox was in itself an inflammatory disorder, we have no certain criterion to know, whether a subject has a disposition towards inflammation. 3. If we had such a criterion, we should still be at a loss to determine to what degree this disposition ought to be lessened. 4. Lastly, the means employed for that purpose, which are chiefly bleeding and purging, may, and often have, a contrary effect.