Part 1

AN

ACCOUNT

Of the MANNER of

Inoculating for the SMALL POX in the EAST INDIES.

[Price One Shilling.]

AN ACCOUNT Of the MANNER of Inoculating for the SMALL POX in the EAST INDIES.

WITH SOME

OBSERVATIONS

ON

The PRACTICE and MODE of Treating that DISEASE in those Parts.

Inscribed to the Learned

The PRESIDENT, and MEMBERS of the COLLEGE of PHYSICIANS in LONDON.

By J. Z. HOLWELL, F. R. S.

LONDON:

Printed for T. BECKET, and P. A. DE HONDT, near Surry Street, in the Strand.

MDCCLXVII.

AN

ACCOUNT

Of the MANNER of

Inoculating for the SMALL POX in the EAST INDIES.

On perusing lately some tracts upon the subject of Inoculation, I determined to put together a few notes relative to the manner of Inoculation, practised, time out of mind, by _the Bramins of Indostan_; to this I was chiefly instigated, by considering the great benefit that may arise to mankind from a knowledge of this foreign method, which so remarkably tends to support the practice now generally followed with such marvellous success.

By Dr. SCHULTZ's account of Inoculation, page 65, note (9), it should seem, that the world has been already obliged with a performance of the kind which I have now undertaken, by a Dutch author, a friend of Mr. CHAIS; but as this is all I know of that work, it shall not discourage my proceeding with my own, the more especially as that performance is in a foreign language, and may not much benefit my country.

As many years are elapsed, since a theme of this nature has employed my thoughts and attention; I will hope for every favorable indulgence from the candor of that learned and respectable Body, to whose judgment I most readily submit the following history and observations.

It has been lately remarked by a learned and judicious ornament of the College of Physicians, "That the Art of Medicine has, in several instances, been greatly indebted to Accident; and that some of its most valuable improvements have been received from the hands of Ignorance and Barbarism; a Truth, remarkably exemplified in the practice of INOCULATION of the SMALL POX."—However just _in general_ this learned Gentleman's remark may be, he will, as to his _particular reference_, be surprized to find, that nearly the same salutary method, now so happily pursued in England, (howsoever it has been seemingly blundered upon) has the sanction of remotest antiquity; but indeed with some variations, that will rather illustrate the propriety of the present Practice, and promote the obvious very laudable intention, with which that Gentleman published his late Essay on this interesting subject.

The general state of this distemper in the Provinces of Bengall (to which these observations are limited) is such, that for five and sometimes six years together, it passes in a manner unnoticed, from the few that are attacked with it; for the complexion of it in these years is generally so benign as to cause very little alarm; and notwithstanding the multitudes that are every year inoculated in the usual season, it adds no malignity to the disease taken in the natural way, nor spreads the infection, as is commonly imagined in Europe. Every seventh year, with scarcely any exception, the Small Pox rages epidemically in these Provinces, during the months of March, April, and May; and sometimes until the annual returning rains, about the middle of June, put a stop to its fury. On these periodical returns (to four of which I have been a witness) the disease proves universally of the most malignant confluent kind, from which few either of the natives or Europeans escaped, that took the distemper in the natural way, commonly dying on the first, second, or third day of the eruption; and yet, Inoculation in the East, has _natural fears_ and _superstitious prejudices_ to encounter, as well as in the West. The usual resource of the Europeans is to fly from the settlements, and retire into the country before the return of the Small Pox season.

It is singularly worth remarking, that there hardly ever was an instance of a native of the Island of St. Helena, man or woman, that was seized with this distemper in the natural way (when resident in Bengall,) who escaped with life; altho' it is a known fact the disease never yet got footing upon that Island. Clearly to account for this, is not an easy matter; I will venture, however, a few conjectures on the occasion. These people rarely migrate from the Island before they arrive at years of maturity; the basis of their diet there, from their infancy, is a root called _yam_, of a _skranshee kind_, a term they use to express its acrid, unwholesome qualities, which frequently subjects them to epidemic and dangerous dysenteries, and sometimes epidemic putrid sore throats. The blood thus charged, must necessarily constitute a most unlucky habit of body to combat with any acute inflammatory disease whatsoever, but more especially of the kind under consideration (so frequently attended with a high degree of putrefaction,) always fatal to these people, even in those seasons when the disease is mild and favorable to others: But indeed it is a general remark, that a St. Helenian rarely escapes when seized with the Small Pox in whatsoever part of the Globe he happens to reside. The same has been observed of the African Coffries, altho' I know not what cause to ascribe it to, unless we suppose one similar to that above mentioned, to wit, some fundamental aggravating principle in their chief diet. Be this as it may, that these two portions of the human species seem peculiarly marked as victims to this disease, is a fact indisputable, let the cause be what it will.

Having thus far premised touching the general state of this distemper in the Provinces of Bengall, (which I believe is nearly applicable to every other part of the Empire) I will only add a few words respecting the duration of it in Indostan, and then hasten to the principal intention of this short Essay.

The learned Doctor FREIND in his History of Physic from the time of GALEN, has this remarkable passage: "By the earliest account we have of the Small Pox, we find it first appeared in _Ægypt_ in the time of _Omar_, successor to _Mahomet_: though no doubt, since the _Greeks_ knew nothing of it, the _Arabians_ brought it from their own country, and might derive it originally from some of the more distant regions of the _East_." The sagacity of this conclusion, later times and discoveries has fully verified; at the period in which the _Aughtorrah Bhade_ scriptures of the Gentoos were promulged, (according to the Bramins three thousand three hundred and sixty six years ago;) this disease must then have been of some standing, as those scriptures institute a form of divine worship, with _Poojahs_, or offerings, to a female Divinity, stiled by the common people _Gootee ka Tagooran_ (the Goddess of Spots,) whose aid and patronage are invoked during the continuance of the Small Pox season, also in the Measles, and every cutaneous Eruption that is in the smallest degree epidemical. Due weight being given to this circumstance, the long duration of the Disease in Indostan will manifestly appear; and we may add to the sagacious conjecture just quoted, that not only the _Arabians_, but the _Ægyptians_ also, by their early commerce with India through the Red Sea and Gulf of Mocha, most certainly derived originally the Small Pox (and probably the Measles likewise) from that country, where those diseases have reigned from the earliest known times.

Inoculation is performed in Indostan by a particular tribe of Bramins, who are delegated annually for this service from the different Colleges of Bindoobund, Eleabas, Banaras, &c. over all the distant Provinces; dividing themselves into small parties, of three or four each, they plan their travelling circuits in such wise as to arrive at the places of their respective destination some weeks before the usual return of the disease; they arrive commonly in the Bengali Provinces early in February, although they some years do not begin to inoculate before March, deferring it until they consider the state of the season, and acquire information of the state of the distemper.

The year in Bengall can properly be divided into three seasons only, of four months each; from the middle of June to the middle of October is the rainy season; from the middle of October to the middle of February is the cold season, which never rises to a degree of freezing; the whole globe does not yield a more desirable or delightful climate than Bengall during these four months; but the freedom of living, which the Europeans fall into at this season, sow the seeds of those diseases which spring up in all the succeeding months of the year. From the middle of February to the middle of June is the hot, windy, dry season; during which no rain falls but what comes in storms of fierce winds and tremendous thunder and lightning, called North Westers, the quarter they always rise from; and the Provinces, particularly Bengall, is more or less healthy, in proportion to the number of these storms; when in this season the air is frequently agitated and refreshed with these North Westers, accompanied with rain, (for they are often dry,) and the inhabitants do not expose themselves to the intense sun and violent hot winds that blow in March, April, and May, it is generally found to be the most healthy of the year; otherwise (as in the year 1744, when we had no rain from the twentieth of October to the twentieth of June) this season produces high inflammatory disorders of the liver, breast, pleura, and intestines, with dysenteries, and a deplorable species of the Small-Pox.

From the middle of July (the second month of the rainy season) there is little or no wind, a stagnation of air follows, and during the remainder of this month, and the months of August and September, the atmosphere is loaded with suffocating heat and moisture, the parents of putrefaction; and nervous putrid fevers (approaching sometimes to pestilential) take the lead, and mark the dangerous season; from these fevers the Natives frequently recover, but the Europeans seldom, especially if they in the preceding May and June indulged too freely in those two _bewitching delicacies, Mangos_ and _Mango Fish_, indiscriminately with the free use of _flesh_ and _wine_; for these (_all together_) load the whole habit with impurities, and never fail of yielding Death a plentiful harvest, in the three last months of this putrid season: If any are seized with the Small-Pox in these months, it is ever of the most malignant kind, and usually fatal. It will not, I hope, be deemed a useless digression, if I bestow a few remarks on the nature of this _Bengall Fever_.

A day or two before the seizure, the patient finds his appetite fall off, feels an unaccountable lassitude, and failure in the natural moisture of the mouth, is low spirited without any apparent cause, and cannot sleep as usual; but having no acute complaint whatsoever, nor preternatural heat, that should indicate a fever, he attributes the whole to the heat of the season, is satisfied with fasting and confinement to his house, or goes abroad amongst his friends to "shake it off," as the common phrase is; but on the third day, finding every one of these symptoms increase, he begins to think something is really the matter with him, and the Physician is called in: thus the only period is lost wherein art might be of any use; for in the course of eighteen years practice I never knew an instance of recovery from this genuine fever, where the first three days had elapsed without assistance, and the patient in this case dyed on the fifth or seventh day. In some, this fever is attended with a full, equal, undisturbed pulse, but obviously greatly _oppressed_; in others, with a low and _depressed_ one, but equal and undisturbed also, and yet both required the same treatment. New comers in the profession, have been often fatally misled by the full pulse, which they thought indicated the loss of blood; they followed the suggestion, the pulse suddenly fell, and when that happens from this cause, the art of man can never raise it again, the patient dies on the fifth or seventh day; and the consequence was exactly the same, if Nature, being overloaded, attempted to free herself of part of the burden by a natural hæmorrhage, or by the intestines, on the second or third day, (which I have often seen) they proved equally fatal as the launcet. Until the close of the sixth day the skin and urine preserved a natural state; but if at this period of the fever the skin suddenly acquired an intense heat, and the urine grew crude and limpid, it was a sure presage of death on the seventh. The natural crisis of this fever, when attacked in the very beginning, and treated judiciously, was regularly on the eleventh day, and appeared in a multitude of small boils, chiefly upon the head, or in small watery bladders thrown out upon the surface of the skin, but in the greatest abundance on the breast, neck, throat, and forehead; both of these critical appearances are constantly preceded, on the tenth day, by a copious sediment and separation in the urine. If by any inadvertent exposure to the cold air, these critical eruptions were struck in, the repelled matter instantly fell upon the brain, and convulsions and death followed in a few hours, and small purple spots remained in the places of the eruptions. Such is the _genuine putrid nervous fever of Bengall_, which never gave way properly to any treatment but that of blisters applied universally, supported by the strongest alexipharmics: sometimes I have seen the crisis (by unskilful management) spun out to the twenty-first day, but it has been ever imperfect, and the patient is harrassed with intermittents or diarrhœas, and commonly dies in the beginning of the cold season; but if he is of a strong constitution, he lingers on, in a dying way, until the month of February, which usually gives some turn in his favor, but his health is hardly ever re-established before the salutary _mango season_, which fruit, eaten with _milk_, proves an effectual and never-failing restorative. But to resume our subject.

The inhabitants of Bengall, knowing the usual time when the Inoculating Bramins annually return, observe strictly the regimen enjoined, whether they determine to be inoculated or not; this preparation consists only in abstaining for a month from fish, milk, and ghee, (a kind of butter made generally of buffalo's milk;) the prohibition of fish respects only the native Portuguese and Mahomedans, who abound in every Province of the Empire.

When the Bramins begin to Inoculate, they pass from house to house and operate at the door, refusing to inoculate any who have not, on a strict scrutiny, duly observed the preparatory course enjoined them. It is no uncommon thing for them to ask the Parents how many Pocks they chuse their Children should have: Vanity, we should think, urged a question on a matter seemingly so uncertain in the issue; but true it is, that they hardly ever exceed, or are deficient, in the number required.

They inoculate indifferently on any part, but if left to their choice, they prefer the outside of the arm, mid-way between the wrist and the elbow, for the males; and the same between the elbow and the shoulder for the females. Previous to the operation the Operator takes a piece of cloth in his hand, (which becomes his perquisite if the family is opulent,) and with it gives a dry friction upon the part intended for Inoculation, for the space of eight or ten minutes, then with a small instrument he wounds, by many slight touches, about the compass of a silver groat[1], just making the smallest appearance of blood, then opening a linen double rag (which he always keeps in a cloth round his waist) takes from thence a small pledgit of cotton charged with the variolous matter, which he moistens with two or three drops of the _Ganges_ water, and applies it to the wound, fixing it on with a slight bandage, and ordering it to remain on for six hours without being moved, then the bandage to be taken off, and the pledget to remain until it falls off itself; sometimes (but rarely) he squeezes a drop from the pledget, upon the part, before he applies it; from the time he begins the dry-friction, to the tying the knot of the bandage, he never ceases reciting some portions of the worship appointed, by the _Aughtorrah Bhade_, to be paid to the female Divinity before-mentioned, nor quits the most solemn countenance all the while. The cotton, which he preserves in a double callico rag, is saturated with matter from the inoculated pustules of the preceding year, for they never inoculate with fresh matter, nor with matter from the disease caught in the natural way, however distinct and mild the species. He then proceeds to give instructions for the treatment of the patient through the course of the process, which are most religiously observed; these are as follow:

He extends the prohibition of fish, milk, and ghee, for one month from the day of Inoculation; early on the morning succeeding the operation, four collons (an earthen pot containing about two gallons) of cold water are ordered to be thrown over the patient, from the head downwards, and to be repeated every morning and evening until the fever comes on, (which usually is about the close of the sixth day from the Inoculation,) then to desist until the appearance of the eruptions, (which commonly happens at the close of the third complete day from the commencement of the fever,) and then to pursue the cold bathing as before, through the course of the disease, and until the scabs of the pustules drop off. They are ordered to open all the pustules with a fine sharp pointed thorn, as soon as they begin to change their colour, and whilst the matter continues in a fluid state. Confinement to the house is absolutely forbid, and the inoculated are ordered to be exposed to every air that blows; and the utmost indulgence they are allowed when the fever comes on, is to be laid on a mat at the door; but, in fact, the eruptive fever is generally so inconsiderable and trifling, as very seldom to require this indulgence. Their regimen is ordered to consist of all the refrigerating things the climate and season produces, as plantains, sugar-canes, water-melons, rice, gruel made of white poppy-seeds, and cold water, or thin rice gruel for their ordinary drink. These instructions being given, and an injunction laid on the patients to make a thanksgiving _Poojah_, or Offering, to the Goddess on their recovery, the Operator takes his fee, which from the poor is a _pund of cowries_, equal to about a penny sterling, and goes on to another door, down one side of the street and up on the other, and is thus employed from morning until night, inoculating sometimes eight or ten in a house. The regimen they order, when they are called to attend the disease taken in the natural way, is uniformly the same. There usually begins to be a discharge from the scarification a day before the eruption, which continues through the disease, and sometimes after the scabs of the Pock fall off, and a few pustules generally appear round the edge of the wound; when these two circumstances appear only, without a single eruption on any other part of the body, the patient is deemed as secure from future infection, as if the eruption had been general.

When the before recited treatment of the Inoculated is strictly followed, it is next to a miracle to hear, that one in a million fails of receiving the infection, or of one that miscarries under it; of the multitudes I have seen inoculated in that country, the number of pustules have been seldom less than fifty, and hardly ever exceeded two hundred. Since, therefore, this practice of the East has been followed without variation, and with uniform success from the remotest known times, it is but justice to conclude, it must have been originally founded on the basis of rational principles and experiment.

Although I was very early prejudiced in preference of the cool regimen and free admission of air, in the treatment of this disease, yet, on my arrival in Bengall, I thought the practice of the Bramins carried _both_ to a bold, rash, and dangerous extreme; but a few years experience gave me full conviction of the propriety of their method: this influenced my practice, and the success was adequate; and I will venture to say, that every gentleman in the Profession who did not adopt the same mode, (making a necessary distinction and allowance between the constitutions of the Natives and Europeans,) have lost many a patient, which might otherwise have been saved; as I could prove in many instances, where I have been called in too late to be of any assistance. But to form a judgment of the propriety of this Eastern practice with more precision, it will be best to analyze it, from the period of the enjoined preparation, to the end of the process; as thereby an opportunity presents itself of displaying the principles on which the Bramins act, and by which they justify their singular method of practice.

It has been already said, that the preparative course consists only in abstaining from fish, milk, and ghee; respecting the first, it is known to be a viscid and inflammatory diet, tending to foul and obstruct the cutaneous glands and excretory ducts, and to create in the stomach and first passages a tough, slimy phlegm, highly injurious to the human constitution; as these are the generally supposed qualities of this diet, it seems forbid upon the justest grounds.

Touching milk, which is the basis (next to rice) of all the natives food, I confess I was surprized to find it one of the forbidden articles, until I was made acquainted with their reasoning on the subject. They say that milk becomes highly nutritious, not only from its natural qualities, but principally from its ready admission into the blood, and quick assimulation with it; and that it consequently is a warm heating diet, and must have a remote tendency to inflammation, whenever the blood is thrown into any preternatural ferment, and therefore, that milk is a food highly improper, at a season when the preternatural fermentation that produces the Small Pox ought to be feared, and guarded against by every person who knows himself liable to the disease, or determined to prepare himself for receiving it, either from nature or art. Upon this principle and reasoning it is, that their women, during the course of their periodical visitations, are strictly forbid, and religiously abstain from, the use of milk, lest it should, upon any accidental cold, dispose the uterus to inflammation and ulceration; and from the same apprehension, the use of it is as strictly prohibited during the flow of the lochia, and is avoided as so much poison; our European women, resident in India, have adopted the same precaution from experience of the effect, and will not, on any consideration, at those times, mix the smallest quantity with their tea, a lesson they derive from their Midwives, who are all natives, and generally are instructed in their calling by the Bramins, and other Practitioners in Physic.