The Suttonian Inoculation.
Daniel Sutton, though an empiric, has given his name to the slight and safe method of inoculation which had been used in England for a good many years before his advent. So completely was his name joined to the practice of smallpox inoculation in its later period that in a Bill before Parliament in 1808 it is called “the Suttonian inoculation,” to distinguish it from cowpox inoculation. The idea of attenuating the virus used for inoculation, and of making the effects minimal, was not his. It had been reached empirically years before by Mowbray, of Charleston, in 1738, who carried inoculation from arm to arm to the fifth remove, by Frewen, of Rye, in 1749, who was satisfied with an abstract “variolosity” of the incisions, in cases where there was no eruption at all or only a few pustules that did not fill, by Kirkpatrick, “the most scientific inoculator in London,” who endorsed the doctrine of variolosity, by La Condamine, and most of all by Gatti of Paris.
Gatti used the unripe matter from a previous inoculation and inserted a most minute quantity of it at a very small puncture; and, to make sure that no general eruption should follow, he used the cooling regimen in various ways, including the prolonged immersion of the hands in cold water. Thus he promised his clients “the benefits of inoculation without its risks.” But Gatti’s career of prosperity was cut short by a series of conspicuous failures of his artificial smallpox to prevent the natural or real disease when it was epidemic. One of his patients, the Duchess de Boufflers, a great lady whose salon was frequented by the philosophes and beaux esprits, fell into the natural smallpox two years and a half after her inoculation[927]. So many others in Paris had the same disappointment that a discussion arose in the Faculty of Medicine, the result of which was that the Parliament of Paris prohibited the practice of inoculation, for various reasons, within the limits of the capital.
Gatti’s friend and correspondent in London was Dr Maty, who, “though born in Holland might be considered a Frenchman, but he was fixed in London by the practice of physic and an office in the British Museum[928].” Having conducted the foreign correspondence of the Royal Society, he became in 1765 its secretary in ordinary, and about the same time Principal Librarian of the British Museum. His interest in inoculation, which was shown by his translating La Condamine’s first discourse on that subject in 1755, led him in 1765 to suggest to Gatti that he should write an essay for publication in England, “both to reclaim the thinking part of Paris, and to vindicate his own operations from the contemptuous treatment of his antagonists.” The essay was written in due course, and Maty brought it out in English[929].
Gatti’s own experiments and those which had previously been made in England by the most experienced inoculators had satisfied him of the truth of what he had long suspected, namely, that the operation could be made “still more harmless, though not less efficacious” (p. 29). There would be hardly any fever, certainly a very slight eruption and perhaps none at all (p. 68), It had, indeed, been questioned whether a patient who had but very few pustules, or only one, has had the smallpox as truly as one who has been very full, and whether he is equally safe from catching it. He answers in the affirmative, according to the doctrine of variolosity: “No reason can be alleged, why we should have the smallpox but once, that will not equally hold good for one as for ten thousand pustules” (p. 69). Some, however, will not believe that one pustule is as good as ten thousand, “notwithstanding the obviousness of this truth.” If one were absolutely bent upon giving a certain number of pustules, he would advise to inoculate according to his method (insertion with a needle) at twenty, thirty, or fifty places: “then you would be sure of one pustule at least at each puncture, and, probably, of many more in other parts.” He would do this, however, only to humour prejudice, and with a feeling that he was doing the patient “more harm than was necessary.” He was seriously satisfied of the “sufficiency of a single pustule,” and believed that every wise man should run the venture of it and “embrace the method here laid down.”
There was no theoretical objection to this method, but there was the practical one, that it might be too slight in its effects. Patients could hardly rest satisfied with so little to show for smallpox; and inoculators themselves found that they might have all their work to do over again. An eminent Irish physician wrote in 1765 to Dr Andrew, of Exeter, that crude matter from a previous inoculation was “less communicative of the disorder and more apt to disappoint us” than matter from a natural smallpox eruption taken “five or six days before the maturation of it[930].” It was also the experience of Salmade, of Paris, in 1798, that serous matter, taken from arm to arm through a long succession of cases, was apt to go off altogether, or to be “weakened to the point of nullity,” whereby it disappointed the operator[931]. Reid, of Chelsea Hospital, was said to have carried the succession to thirty removes from the natural smallpox. Bromfeild knew for certain of matter being used at the sixteenth remove.
So long as the operation held at all, and had not to be repeated, Dr Andrew believed that effects which “no one would have taken for the smallpox,” were “sufficient security against any future infection[932].” Heberden, indeed, has recorded a case adverse to that view; but one case is not enough, even if it had been in as eminent a person as Madame de Boufflers[933].
Daniel Sutton, who gave his name to the slighter kind of smallpox inoculation, was not a regular practitioner. His father, a doctor of medicine in Suffolk, was a specialist inoculator, as others of the regular profession here and there were becoming, and had operated upon 2514 patients from 1757 to 1767. In 1763 Daniel began business on his own account at Ingatestone in Essex, where patients from all parts were boarded and subjected to his regimen, as at a water-cure. In 1764 he made 2000 guineas, and in 1765 £6300. In the three years 1764-66 he inoculated 13,792 persons, and his assistants some 6000 more—without a single death. Sutton kept his method at first a secret, and for that reason was looked at askance by eminent physicians. He used pills and powders, which were found, by the analysis of Ruston, to be a preparation of antimony and mercury, the drugs supposed to be antidotes to natural smallpox, or the means of preventing its pustular eruption. But the essence of his method was found to be, in Chandler’s words, “the taking of the infective humour in a crude state [from a previous inoculation] before it has been, if I may allow the expression, variolated by the succeeding fever[934],” or, in Dimsdale’s words, “inoculating with recent fluid matter,” or in Sir George Baker’s words, “with the moisture taken from the arm before the eruption of the smallpox, nay, within four days after the operation has been performed[935].”
Sutton made it known that the effects of this method were exceedingly mild—no keeping of bed, no trouble at all: “if any patient has twenty or thirty pustules, he is said to have the smallpox very heavy.” Being put on his trial at Chelmsford for spreading abroad the contagious particles of smallpox by the number of his inoculations, his defence was to have been (if the bill had not been thrown out by the grand jury), that he “never brought into Chelmsford a patient who was capable of infecting a bystander.” The mildness of his artificial smallpox was acknowledged with satisfaction by some, with dissatisfaction by others. Dr Giles Watts, an inoculator in Kent, says it was “a most extraordinary improvement. The art of inoculation is enabled to reduce the distemper to almost as low a degree as we could wish.... There is now an opportunity of seeing what a very small number of the multitude of persons of all ages, habits and constitutions, who have been inoculated in these parts, have been ill after it.” Comparing it with the method which he had practised before, he says that he never knew ten or twelve inoculated together “in the old way” but one or more had the distemper in a pretty severe manner; on the other hand, he had inoculated four of his children in the new way and all of them together had not so many as eighty pustules. He adds that sometimes the inoculated had not even a single pustule (besides the one at the point of insertion) or at other times not more than two or three[936].
The Suttonian practice was objected to by Bromfeild in an essay dedicated to Queen Charlotte. Tracing it to Gatti, whose manifesto had been published in England two years before, he said that it was mere credulity “to have given credit to a man who should assert, that he would give them a disease which should not produce one single symptom that could characterize it from their usual state of health.... Inoculation, though hitherto a great blessing to our island, will in a very short time be brought into disgrace,” if it were assumed “that health and security from the disease can be equally obtained by reducing the patients so low as only to produce five to fifteen pimples[937].”
Bromfeild was not openly supported except by Dr Langton, of Salisbury, who contended that “the matter communicated is not the smallpox, because numbers have been inoculated a second, third and fourth time, that therefore it is no security against a future infection.” He cites Gatti’s case of the Duchess de Boufflers, and declares, as to the English inoculations, that not above one in ten have so many variolous symptoms as may be remarked in her case. “The old method of inoculating,” he says, “was to take the infection from a good subject where the pustules were well maturated, whereby the operation was sure of succeeding; but the present practice is to take the matter from the incision the fourth day after the incision is made [this was Sutton’s avowed practice]. By this means you have a contagious caustic water instead of laudable pus, and a slight ferment in the lymph is raised, producing a few watery blotches in the place of a perfect extrusion of the variolous matter[938].”
There was no difference of opinion as to the exact purport and upshot of the new method; it was to reduce the eruption to the lowest point or to a vanishing point. Nothing can be more emphatic than Gatti’s profession of belief that a single pustule, at the place of insertion, was as effectual as ten thousand; and it is not only likely, on the face of it, that such a mitigation as Reid’s to the thirtieth remove from natural smallpox, would produce merely the local pustule, but it is clear that Gatti saw no way of ensuring more by his method, supposing he were to gratify the prejudices of the laity in favour of more, than by puncturing the skin at twenty, thirty, or fifty separate points. It is not to be supposed, however, that the minimum result was obtained in all cases, or that all inoculators were equally adroit in procuring it; even Sutton had to admit that some of his thirteen thousand patients had more pustules on the skin than he desired.
Perhaps the most exact record of the number of pustules produced in a comparative trial of various methods is that of Sir William Watson at the Foundling Hospital in 1768[939]. Of 74 children inoculated in October and November, twelve had no eruption at all, but yet were held to have been protected by the operation. The remaining sixty-two had a very small average of pustules in addition to the local pustules, which average, small as it was, came mostly from two or three severer cases (e.g. one with 440 pustules, one with 260, and one with near 200), the most having three or four or a dozen or perhaps two dozen (e.g. three had only 7 pustules among them, or, in another batch of ten done with crude or ichorous matter, “the most that any boy had was 25, the least 4, the most that any girl had was 6, the least 3,” or, in another batch of ten, also with crude lymph, two had no eruption, seven had 35 pustules among them, and one had 30). Of the amount of smallpox upon the whole sixty-two cases which had some eruption Watson says: “Physicians daily see in one limb only of an adult person labouring under the coherent, not to say confluent smallpox, a greater quantity of variolous matter than was found in all these persons put together.”
Watson’s sole measure of “success” in inoculating was the slightness of the effect produced; and as he found that crude or watery matter from the punctured spot of a previous inoculation had the least effect, he decided to use that kind of matter always in future at the Foundling Hospital. On the other hand, Mudge, of Plymouth, raised a different issue and put it to the test of experiment on a large scale. Did crude matter infect the constitution? Did it make the patient insusceptible of the effects of a second inoculation with purulent matter? The experiment came out thus:
At Plympton, in Devonshire, in the year 1776, thirty persons were inoculated with crude or watery matter from the arm of a woman who had been inoculated five days before, and ten persons were at the same time inoculated with purulent matter from the pustules of a case of natural smallpox. The thirty done with crude matter had each “a large prominent pustule” at the place of puncture, “but not one of them had any eruptive fever or subsequent eruption on any part of the body.” Matter taken from their local pustules produced exactly the same result in the next remove, namely, a local pustule, but no eruptive fever nor eruptive pustules. The thirty were inoculated again, this time with purulent matter (five from natural smallpox, twenty-five from inoculated smallpox), and all of them had, besides the local pustule, an eruptive fever and an eruption “in the usual way of inoculated patients.” The ten who were originally inoculated with purulent matter had that result at first[940].
In the subsequent history of inoculation it would appear that the method known by the name of Sutton, of using crude or watery matter from a previous inoculated case, was the one commonly preferred. But it was not always preferred. One of the medical neighbours of the afterwards celebrated Dr Jenner took matter from the pustules and kept it in a phial; his patients inoculated therewith had somewhat active effects, even “sometimes eruptions.” But “many of them unfortunately fell victims to the contagion of smallpox, as if they had never been under the influence of this artificial disease,” so that Jenner, who had probably not heard of Mudge’s experiment, was confirmed in his preference for the crude matter (before the eruptive fever) from a previous inoculation. It was of great importance, he said, to attend to that point, as it would “prevent much subsequent mischief and confusion[941].” Of course there were many more chances of getting matter from natural smallpox than from inoculated; but it would appear that in the former also it was taken in the ichorous or unripe stage of the eruption, according to the practice of Sutton, and despite the experimental proof that Mudge gave of its merely superficial or formal effects.
Mudge’s experiment was on a large scale, and designed to test a general or scientific issue. The testing experiment usually made was merely for the sake of the particular case; the patient was inoculated a second time, shortly after the first, with the same matter as before, or a third time, or even a fourth time. Whatever the significance of this for the doctrine of inoculation in general (as in the issue raised by Mudge), the individual was both reassured and fortified so far as concerned his own safety. The experiment of the former generation that was usually cited was that of the Hon. John Yorke. On his leaving the university at the age of one and twenty it was thought prudent that he should be inoculated for smallpox before entering on the great world. He was inoculated by serjeant surgeon Hawkins, and had the local suppuration, some fever, but little or no eruption. The inoculator was satisfied, but not so the youth: he insisted upon a second inoculation, which had no effect. This was considered a leading case. When the Suttonian method came in, and the absence of eruption (barring a few pimples or bastard pustules) became the usual thing, the occasions for a second inoculation became more common, owing to the prejudice, as Gatti said, of the laity in favour of something tangible although not excessive[942].
Dimsdale inoculated many of his patients a second time, and produced the local pustule again, as at first. Of the 74 foundlings in Watson’s experiment of Oct.-Nov. 1767, there were twelve who had no eruption, of whom four were re-inoculated with no better result or with no result. Of the whole twelve he says: “Although they had no eruption, I consider them as having in all probability gone through the disease, as the punctures of almost all of them were inflamed and turgid many days.” It was so unusual for a second inoculation, in a doubtful case, to produce more than the first, that Kite, of Gravesend, communicated to the Medical Society of London two cases where that had happened, as being “anomalous.” He had never before been able to communicate the smallpox, on a second attempt, “to any patient whose arm had inflamed, and who had even a much less degree of fever” than Case 1, who had only the local pustule and “on the eighth day was quite well:” and he cites Dimsdale to the same effect[943].
Perhaps enough has been said to illustrate the subtle casuistry that had gradually arisen out of the old problem of procuring the smallpox by artifice. I make one more citation, from a Hampshire inoculator in 1786, to show how fine were the distinctions, depending, one might suppose, upon the subjective state of the practitioner, drawn between effective and non-effective inoculation:
“The incisions sometimes have a partial inflammation for a few days, which then vanishes without producing any illness; in this case the patient is certainly still liable to infection; but I believe it very rarely happens that there is any matter, or even ichor, in the present slight manner they are made, without producing the smallpox.... I have constantly remarked that when the punctured part inflames properly, and is attended with an efflorescence, rather inclining to a crimson colour, for some distance round the same, about the eleventh or twelfth day from the inoculation, although the patient should have very little illness and no eruption, yet that he is secure from all future infection[944].”