New Observations on Inoculation/Chapter 1
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 operations. 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,
Ma per volere star meglio
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.
These two objections are the only rational and intelligible ones, that can be alledged against my assertion with regard to the inutility and dangers of preparation. As to others, grounded upon the necessity of sweetening the humors, purifying the blood, cooling it, &c. (forms of speech unfortunately in vogue in the world) I own I do not understand the meaning of these words, and I am convinced no body does. I may therefore spare myself the trouble of shewing the absurdity of all rules founded upon these notions; and shall take it for granted, that all sensible people must be satisfied that a subject who is not well should be cured, and not inoculated; and that one who is well ought to be inoculated, but never be prepared.
Many inoculators, being aware of the inconveniences of regularly preparing a healthy person, have contrived specific medicines, in order to diminish the energy of the virus, and in consequence to lessen the disorder. I have tried some of these specifics; such as. mercury, antimony, the bark; but always found they did more harm than good. I may, indeed, have used them in an improper manner, or there may be other species that I am not acquainted with; but since those patients who did use them, had not a slighter disorder than those who did not, I cannot help looking upon them as bordering upon quackery. May they not be deemed a contrivance to secure to operators that advantage, which perhaps gave rise to preparations, by inducing the public to attribute the success of inoculation to the skill of the inoculator?
I shall close this article by appealing to experience, the great, and perhaps the only, test in medical matters. It strongly confirms the principles I have laid down.
In those countries, where inoculation has been most successful, where it is attended with little or no danger, where thousands are inoculated, and are hardly sick at all, in a word, throughout the East, the operators only enquire, whether the person is in full health.
The history of inoculation in Europe must convince any man, who does not wilfully shut his eyes against light, both of the inutility and danger of preparations; by shewing, in the several countries where inoculation has prevailed, how these preparations have been productive of untoward consequences, in proportion to the use that has been made of them; and how accidents are become less frequent, in proportion as preparations have been more simple, or quite laid aside.
In the first period of the London inoculations, great stress was laid upon preparation; the method was complicated and tedious, the patients were worse, and more of them died. But since preparation has been more disregarded, the disorder has been slighter, and fewer have been lost. I could quote some of the most eminent and successful inoculators, who wholly omit preparation, and some who openly declare against it.
Even in France it is visible that, within these five or six years, inoculation is become more successful, and is attended with fewer bad consequences, since less stress has been laid on long and severe preparation. Let those physicians, at Paris, who, practice inoculation, declare, whether it is not strictly true, that they have relaxed from the severity of their preparations; and whether inoculation is not now more prosperous in their hands, than it was some few years ago?
Give me leave here again to alledge what I have met with in my own practice. I may safely say, that those of my patients, who have fared best, have been such as had been no otherwise prepared than by stating or restoring their health; and when the disorder has been more violent, or has left any bad remains, it has constantly been in such as I had more or less prepared, according to rules.
Lastly, of all the cases where inoculation has proved mortal or dangerous, not one perhaps will be found upon enquiry, where the patient had not been previously prepared; and to the excessive care in this article, physicians themselves have often imputed their ill success. This being the result of all I have read or observed concerning inoculation, let the consequence be drawn; I think it cannot be favourable to the doctrine of preparation.
This doctrine has not only been laid aside or softened by physicians in their practice, but if you look into the works published from time to time both in England and France, you will find, that even in theory, the severity and importance of preparation is much less insisted on; and the latest writings come very near my opinion.
One of our most eminent physicians, in a work printed four years ago, asserts, that every subject must be prepared at least for one month; and that during that time he is to be blooded, physicked, and vomited, &c. But in later times Dr. Petit, the author of the excellent Report in favour of Inoculation, says, that if the subject is healthy, strictly speaking, he wants no preparation; and that if he is sick, the preparation consists in the curing of him. Could the contrast between the two methods be more striking?
But it would be trespassing upon the patience of my readers, to take up any more of their time in proving this self-evident truth, that the best disposition for having the small-pox safely is health; and that this disposition, when found in any subject, ought by no means to be disturbed under pretence of preparing him.
All that is requisite is to ascertain this disposition, and this is easily done. Health, we all know, is the faculty of exercising constantly, and with ease, all the functions suitable to the age, the sex, or the constitution of each individual. Now any one is able to judge whether a subject has, or has not, that faculty; and the person himself, or those about him, can tell that with more certainty than any physician whom they could consult. A man is in health when no pain or weariness warns him of any disorder in his frame.
Although it is impossible to determine geometrically the degree of health requisite for inoculation, you may safely trust to that indeterminate judgment we commonly pass, when we say, such a one is well: we mean that nothing amiss is observable, nothing at least that attacks the vital functions, nor any tendency to sickness, as in children during dentition, or women during pregnancy, &c.
But besides this general rule, the fitness for inoculation may be determined with greater certainty by a few plain and easy signs; viz. 1. the sweetness of the breath; 2. the thinness of the skin; 3. the facility of cicatrisation. I do not know whether these signs only indicate the state of which we call health, or whether they denote those unknown qualities, which are favourable to the action of the virus: but certain it is, that I have always found them to be attended with a mild small-pox, in proportion to the degree in which they were observed.
- Observations sur la petite verole naturelle & artificielle.