Thevery great relief which persons under inoculation experience from fresh air, cold water, and evacuations by stool, during the fever preceding eruption, soon determined me to make trial how far the like treatment might be useful to those who might be seized with the small-pox in the natural way; more especially in such cases, where, from the violence of the symptoms, a confluent kind was justly to be apprehended.
But opportunities of making experiments of this sort in a satisfactory manner are rare. First, because a physician, or even medical assistance of any kind, is not often called in till the eruption shews itself; when it is too late to expect all the good effects that might be hoped for, from an earlier trial of this method: and secondly, because the first attack of the small-pox is so much like the beginning of some other fevers as not easily to be distinguished; though a diligent attention to the symptoms, will generally, if we are called in time, enable us to form a pretty certain prognostic. For if the attack of the cold fit be pretty severe, and the subsequent fever unusually high; if a nausea and vomiting succeed, together with great pains in the head, back, and loins, especially in the last; if a delirium, great restlessness, disagreeable taste in the mouth, and a peculiar fœtid smell in the breath, or even if several of these symptoms are observed, the small-pox may with great reason be expected; and if upon inquiry, which should always be made, it appears that the patient has been in the way of infection, there will be little reason to doubt it.
It may be objected, that notwithstanding the closest attention and inquiry, symptoms of the like nature may precede fevers of other kinds; to which I answer, that some such cases, though few, have happened; and the treatment I am about to recommend has been practised not only without prejudice to the patient, but manifestly to his benefit.
But waving for the present all considerations respecting the treatment of fevers ingeneral, I shall only relate what has occurred to me in respect to the natural small-pox.
In several instances where I have been concerned, and where the symptoms and other concurring circumstances induced me to think the small-pox was at hand, I have directed the like management as I recommend to inoculatedpatients5.
I have been called also to others at the time of eruption, where some pustules having already appeared, made the matter clear; and in every case of this kind, I have endeavoured to get the sick person into the open air, have generally given the mercurial and antimonial pill, and directed a laxative to be taken some hours after it, in order to procure three or four stools; and this method I have more particularly enjoined, and sometimes repeated, where the kind has appeared to be bad, and where little or no relief has been found from the partial eruption; the symptoms continuing to be such as portended great danger. I have followed the same method duringevery part of the eruptive fever, intending thereby to abate its violence, to check the eruption, and prevent the conflux, and consequently thedanger6.
The success attending this practice has hitherto exceeded my expectations; though it must be confessed, that as the symptoms run much higher in the natural, than they are found to do in the inoculated disease, the relief has not been so considerable; and I have found it extremely difficult to persuade such whose complaints have been very severe, to quit their beds, and attempt to go abroad: indeed the exceeding feeble state they are sometimes in, sufficiently shews that great resolution is requisite to put this in practice.
Among those who have been treated in this manner under my own care and inspection, not one has died, and the number amounts to about 40. Some of the most remarkable cases will be subjoined,which will more satisfactorily explain the practice, and demonstrate its success.
The immediate sensible effects of going into the open air, are, a very great abatement of heat upon the whole surface of the skin, which, though but just before intensely hot, generally in a short time feels not much warmer than that of a person in health: the pulse, from being very strong, full, and quick, becomes less hard and full, but continues quick; and I have sometimes observed it to intermit; which, however alarming it may seem, is not a dangerous symptom.
The pain in the head is always relieved, but that in the back and loins does not abate in proportion: and although it costs no little pain and trouble to persist in moving abroad under such circumstances, attended for the most part with great lassitude, yet the patients are sensible of the benefits they receive; and entertaining a good opinion of the usefulness of the practice, commonly behave with great resolution; and, what is very encouraging, in general think themselves stronger.
Upon going within doors to rest themselves, the pain in the head grows worse, but is again relieved as soon as they return into the air.
The effects of the medicines are usually these:
If there has been much sickness at stomach, a vomiting frequently happens soon after the pill: this the patients should promote by drinking plentifully of some warm diluents; and till the fatigue occasioned by it is over, they certainly ought not to go abroad.
By this operation, and the stools which succeed, the feverish and internal heat, the thirst, sickness, and pains, are for the most part considerably abated. The patients commonly complain of being very low and faint after these evacuations; but the mosturgent symptoms being alleviated thereby, a disposition to receive nourishment hourly increases. They are then allowed to drink thin mutton or chicken broth, milk pottage, or tea, as the most grateful and refreshing cordial sustenance they can take. Sleep likewise now most commonly comes on spontaneously. But they are permitted to enjoy this refreshment by day upon the bed only; for I always dissuade them from going into it till night.
From the foregoing account it appears, that the fever preceding eruption, and the most grievous symptoms accompanying it, are often greatly mitigated by this practice; and I will here add, that the eruption is most certainly retarded, that is, it does not appear so soon after the attack of the disease, nor come out so precipitately when it has begun to appear, as it seemed likely to have done if the natural progress had not been interrupted; an effect, which, however dangerous it may have been thought, may be produced with the utmost safety, and clearly shews the utility of the practice.For it is evident from experience, that the later the eruption shews itself after the beginning of the disease, and the slower it comes out, the more mild and favourable is the subsequent disorder. And I am of opinion, that the eruption is not only retarded and protracted by this method, but likewise that it is in some degree repressed; having had strong reasons to apprehend, in several instances, that the number of pustules, which appeared at first, were by such repression actually diminished; and those that remained seemed larger, and of a milder kind.
What has hitherto been said on the subject, relates only to the disease in its eruptive state, which is certainly a very interesting period; but that which follows is not less so, though not always attended to so much as it deserves: for when the eruption is completed, the symptoms abate, the patients seem relieved, and often to such a degree, that both they, and their attendants, flatter themselves with hopes of a happy event, and think it unnecessary toapply for any medical assistance; yet with all these hopeful appearances, the number and kind of the small-pox are frequently such, as would make a judicious practitioner apprehensive of much danger in the subsequent stages.
And where the practitioners themselves may see reason to doubt of the event, yet few or none of them have attempted, I believe, to do much towards preventing the danger; for, unless some pressing symptoms call for immediate relief, it is the general practice to wait till maturation comes on, and brings with it such a train of dreadful complaints, as are more than enough to employ, and too often baffle the best abilities.
In this neglected interval, from the eruption being completed, to the accession of the fever of maturation, and its concomitants (an interval which, in point of duration, is very different in different constitutions and kinds of small-pox); I will venture in general to recommend the same mercurial antimonial medicine as was prescribed in the eruptive fever, to be repeated at proper intervals, till the maturation advances; at which time it must certainly be discontinued: and these circumstances can be regulated only by those who attend, according to the urgency of the symptoms, and the strength of the patients: a cupful of the following apozem should, if necessary, be now-and-then taken after the mercurial medicine; often enough to procure three or four stools a day, especially if the patient is costive.
Take cream of tartar, two drachms; of manna, one ounce; dissolve them in one quart of barley water, or the pectoral drink.
How far it may be safe or advisable for the patients to venture out into the open air during this stage of the disease, I will not yet pretend to say; but they will certainly be both refreshed and invigorated, by being kept out of bed as much as they can bear, without being over-fatigued; and by fresh air let in sometimes through an open window.
As the violence of the eruptive fever, with its attendant complaints, must necessarily exhaust the strength and spirits, both should in this interval be recruited, by as much proper nourishment (such as has been mentioned in the former part of this chapter) as can be taken down without offending the stomach; and also, if occasion requires, with medicines of a cordial and anodyne quality: for this is the time to recover as much strength as possible, in order to be better able to encounter and bear the pain and fever, which will most certainly happen, as the state of maturation advances.
Medicines, except what have been already mentioned, seem at this time unnecessary; and they would interfere with, and prevent the true relish for, food.
But for the best method of treating the small-pox in its most dangerous stage, I mean that of maturation, I must refer to the several learned and eminent practitioners who have professedly written upon the subject, whose opinions and practice I neither pretend to correct or amend. I shallhowever take the liberty to recommend one medicine to be used in that stage of the disease, which I have found to abate heat, and allay thirst, in such a manner as to afford a very pleasing refreshment.
Take of the weak spirit of vitriol one part, of the sweet spirit of vitriol two parts; mix. Of this the quantity of half an ounce may be added to a quart, or perhaps three pints, of barley water, or the pectoral drink, or any other diluent, and to be drank of at pleasure.
I have at present nothing farther to recommend; but what has been said will I presume be sufficient, with the cases annexed (in which the method will be more plainly described) to justify farther trials of the cooling, repelling, and evacuating practice in the beginning, at least, of the natural small-pox, till the eruption is completed; especially where the physician has an opportunity of making the trial before the eruption appears, and can be pretty certain, or has good reason to conclude, that hispatient’s disorder is variolous. And the more violent the symptoms are in this stage of the disease, the more we should be induced to employ the means which have been attended with so much success, in the same stage of the disease after inoculation.
But it may be asked, if I was called to a patient in a bad confluent small-pox, and finding the eruption completed, whether in such a case I should venture to give and continue the use of the alterative and purgative medicine; and advise the patient to go out, if he can bear it, into the open air in cold weather, or direct air to be let in through a window even while the mercurial purge may be operating.
Before I give a direct answer to this question, let me first ask the most experienced practitioner, whether he knows any method of cure which may in bad cases be safely relied on, to avert the impending danger, and save his patients? The too well known fatality of all kinds of small-pox, very clearly proves that he does not, and that no such method has yet been discovered. And ifthis be the case, surely a bold, and even hazardous practice, is very justifiable towards any such unhappy patients, who lie as it were under sentence of a cruel death, not to be prevented by what are called the regular and usual methods. But still it may be urged, that no impending danger, however great, can sufficiently justify the trial of any hazardous experiment, unless supported by some degree of reason or experience. Happy, indeed, it is, when we have these two guides before us; but when they are separated, the latter is certainly most to be relied on, and her I have endeavoured hitherto to follow.
For in the practice of inoculation experience has taught me, that after as well as before the eruption, persons may safely take mercurial purges, and go out during their operation (though I have seldom advised any to do so) into the cold air, in inclement weather, without suffering the least harm or subsequent ill consequence from it. And by this experience I was led, though with great caution, to try whether the same practice might not be safely employed in thecure of the natural small-pox, as well as the inoculated; nor have the trials been unsuccessful: for though among the patients I have treated in this manner, some had confluent sorts, yet were the complaints unusually moderate throughout the whole progress of the disease, and the maturation was completed, without such troublesome and alarming symptoms and events as might be expected under any other known method of treatment; nor did any secondary fever ensue.
I would not, however, be understood to entertain so good an opinion of this method, as to insinuate that it will save all who have the bad confluent kind; too many of these are incurable; but I am not without hopes, that it may give a chance of recovery, hitherto untried, to many: and even if this alterative and evacuating course in the early part of the disease should not succeed, so as to avert the approaching danger, I think there is great reason to suppose that nourishment, cordials, and opiates, which may be wanted in the state of maturation, will be administered with more advantage andsecurity after it, than if that method had not been previously taken.
It seems necessary, however, to declare, that nothing which has been said is meant to relate to practice in the bleeding or purple small-pox; though very cold repellent methods may perhaps deserve to be tried in these hitherto fatal cases, provided it can be done early; but the mercurial evacuating course seems quite improper.
Upon the whole, what has been said on the natural small-pox, must wait the award of time and experience, the only tests of the utility of any practice; for I have lived long enough to have seen several instances where very ingenious and well-meaning men have been greatly mistaken, by relying too much on the first impressions made by a few successful experiments.
BeforeI dismiss the subject, it may not be improper to give some account of the motives that induced me to adopt this method.
During the course of many years practice of inoculating in the former usual method, I generally committed to writing the most remarkable occurrences to have recourse to. Among these, I had recorded some cases, which proved, that those who had suffered most, were in general such as have been kept warm, and nursed with the greatest tenderness and care. These facts disposed me to think of a cooler manner of treating the disease, and made me attentive to the reports of such a method having been practised in some parts of this country with great success, though too extravagant at first to deserve credit.
The reports, however, of this practice still gained ground; and, upon the strictest inquiry, I found they were for the most part true, and that such who were treated in this way, passed through the distemper in a more favourable manner than my own patients, or those of the most able practitioners in the old method of inoculation; also that the inoculators in this new way, enjoined a stricter regimen as to diet, than I had hitherto thought necessary; and that they frequently brought their uninfected patients into the presence of those who had the disease, and inoculated them immediately with fluid matter, taken on the point of a lancet, and by a very slight puncture or incision; applying no dressing or covering afterwards.
This way of performing the operation pleased me, as far as related to the slightness of the incision, and the use of fresh matter; for I had (in common with other inoculators) sometimes failed of infecting, by using a thread that had been kept too long in a phial: but the circumstance ofbringing the person to be inoculated into the presence of one who had the small-pox, seemed hazardous, lest there might be an accumulation of infection.
All doubts, however, were at last removed by the authenticated accounts that I received of these particulars, and of the good success that attended the practice; and I began to try it in January 1765; when, after having directed a strict regimen and some mercurial purges, I inoculated with fluid matter, proceeding with much circumspection and attention; my patients being exposed to the open air in that cold season. The great advantage they received from this treatment was soon apparent, and more than sufficient to encourage my continuance in the practice; till repeated experiments induced me to think, that instead of supposing the fever in the small-pox to be the instrument employed by nature to subdue and expel the variolous poison, we should rather consider it as her greatest enemy, which, if not vigorously restrained, is apt to produce much danger;and that all such means should be used as are most likely to control its violence, and extinguish the too great fervor of the blood. Pursuant to this opinion, besides keeping my patients in the open air, which I had learned from others, I first directed the mercurial and antimonial medicine, and the laxative course in the eruptive state; the manner of administering which, and the success attending, has been already related.
It may perhaps appear singular that bleeding has neither been once mentioned or directed in the course of this work, though by general consent it is allowed to be the most efficacious remedy in all inflammatory cases. To this I can only say, that the regimen and medicine above prescribed commonly reduce the patients so much as to render bleeding unnecessary. And in the natural small-pox it seemed most reasonable to adhere, as strictly as possible, to those measures which had contributed apparently so much towards passing so easily through inoculation. I doubt not, however, that cases willarise, in which bleeding may not only be safe, but extremely salutary.
It will, I hope, be needless to tell the reader, that I have disclosed the whole of what I know with certainty relative to this process, as the regimen, medicines, different types of the disease, the rules of prognostic, and various events, &c. are fully and faithfully related, according to the best of my judgment and experience. And I believe, if the method now recommended is carefully pursued, it will be found to answer with a success at least equal to any yet discovered. Nevertheless it is reasonable to suppose, that further experience may produce some improvements: yet when it is considered, how short a time is required for preparation; how few medicines are to be taken; that those medicines are neither nauseous in themselves, nor violent in their operation, and of a kind likely to be beneficial to most constitutions, and hurtful to none, unless injudiciously administered; that the disease is usually so mild, as to require little or no confinement (the complaints of far thegreater number being that they have too little of the distemper); and that the disagreeable consequences which sometimes happened after the former method of inoculation are likewise by this most commonly obviated; I do not see that much alteration can be even wished for. That which appears most likely to be made, is in shortening the time of preparation; for as I have often been obliged to inoculate without any, and have always had the same success, it has inclined me to think, that much, if not the whole, of this process, may be dispensed with, except in very full habits, or where other particular circumstances may require it. But in all these cases, from the insertion of the matter to the time of the eruptive complaints, the patients have been kept to a close observance of diet, and the use of the preparatory medicines, proportioned as well as I could to their condition: for I durst not, by way of experiment, dispense with the use of measures that had been hitherto so successful.
Should it be asked then, To what particular circumstance the success is owing? Ican only answer, that although the whole process may have some share in it, in my opinion it consists chiefly in the method of inoculating with recent fluid matter, and in the management of the patients at the time of eruption. If these conjectures should be true, perhaps we should be found to have improved but little upon the judicious Sydenham’s cool method of treating the disease, and the old Greek woman’s method of inoculating with fluid matter carried warm in her servant’s bosom.
Nov.23d.
A verystrong, fat, middle-aged man was inoculated with fluid matter, from a person pretty full of the natural small-pox, and near the crisis.
26th. He came to me, that I might inspect the arm, which then appeared to be certainly infected, and very forward.
28th. He came to the house, and informed me he had been taken very ill on the 26th in the evening, and continued so all the next day. His complaints had been, great pains in his head and back, with heat, thirst, and restlessness. He was at this time, however, pretty well; but on inspecting the arms, they appeared much inflamed for a considerable space round the incision, and the erysipelatous appearancegradually extended itself over the greatest part of the arms between the elbow and shoulder. He now complained only of slight flying pains in his head and limbs, but without the least degree of fever: after a bad night’s rest several eruptions were discovered on the hips, and one on the neck. Some of these maturated, others dried away; and, upon the whole, the procedure was such as would not by any have been called variolous, if unattended with other circumstances.
Nov. 23d.] A healthy strong man, inoculated at the same time, and from the same person, with the last, accompanied him also on the 26th, when the arm of this patient appeared in a very doubtful state respecting the infection.
On the 28th, when he came to the house, the skin at the incision was discoloured, felt hard, seemed thickened, did not appear inflamed; nor did he allow it had itched, or that he had perceived any alteration in his health.
Things remaining in this state, I inoculated him again on the 30th in the morning, being the eighth day from the first inoculation. On the evening of the same day he complained of chilliness, attended with pain in his head and limbs, and passed an uneasy night. These complaints lasted in a very moderate degree for two days more, but without the least appearance of a fever. A very few pimples were discovered upon the decline of these symptoms, but they soon vanished without maturating.
Nov. 23d.] A third patient, a young man twenty years of age, was inoculated with the two last. I had not seen his arm from the time he was inoculated to the 28th, when he came to the house in company with the others. He said the incised part had itched very much the first three or four days, but it now appeared nearly in the same state as the preceding.
He was also inoculated again on the 30th. But as the succeeding complaints, and doubtful eruption in this case, bore an exactresemblance to those of the former, it is needless to repeat them.
Nothing happened to either from the second inoculation.
1765, May 5th.] A man aged twenty-four was inoculated; after which he went to visit a relation, till it should be thought proper for him to come to the house, which I directed him to do on the 11th, if he should continue well till that time.
He took with him two calomel pills, one of five and the other of ten grains. He was ordered to take the least on the 8th, the other on the following night, and an ounce of purging salts the next morning.
I did not see him till the 11th, when he came to the house: he was then perfectly well, but said he had been a little giddy for the last day or two, and that his head had ached very much the preceding day for about an hour, insomuch that he thought he must have come over; that his arm had itched very much, and the purge had worked very briskly.
Upon examining the arms, both incisions appeared to be considerably inflamed, and looked just as is usual on the approach of the eruptive fever, which I had not the least doubt would soon happen.
On the 12th he complained of some pain in the right shoulder, and under the arm, which he said was stiff, and felt as if it was swelled. However, he continued perfectly well and free from all complaints to the 15th; the arms appearing as is usual when the distemper is attended with very few pustules; that is to say, not quite free from inflammation, but with a slight one.
The case being not so clear as could be wished, in order to be thoroughly satisfied, I inoculated him again, taking particular care to infect the part well.
On the 16th in the morning he took a dose of Inf. Sen. and Manna.
He continued quite well, and no itching or signs of infection appeared from the last inoculation.
May 3d.] A man of 44 was inoculated. I saw him every day, and it was easy to perceive that the infection had taken place very early.
On the 7th it appeared so forward, that I ventured to prognosticate he would have a very early and mild disorder, and no eruption.
On the 8th he complained of a pain in his head and back, and that he felt a general uneasiness, attended with a loss of appetite, which at other times was very good. He continued complaining in this manner that whole day, but on the next found himself pretty well, and continued so without any other illness. The inflamed appearance on the incision abated from this time.
His health returned, and he still remains perfectly well.
A middle-aged man was inoculated at the same time; whose case in every circumstance so nearly resembled the former, as to render it needless to enumerate the particulars.
Both were inoculated a second time without any eruption or signs of infection happening in consequence of it.
Dec. 5th.] A healthy man of 38 was inoculated. On the 7th he called on me, when his arm itched very much, and shewed certain marks of the infection having succeeded.
The inflammatory appearance was then considerably abated, and the incisions seemed disposed to heal. He felt no uneasiness on the part, nor had he any illness.
On the 12th and 13th he complained of pains in his head and limbs, as also of stiffness under his arms, which I esteem one of the most certain proofs of the infection having taken place. There was no alteration in the pulse, nor any other sign of a fever; a few pimples about the neck and arms followed these complaints, yet not such as I should have esteemed variolous onany other occasion: for some soon disappeared; and others, which remained long enough to have a little matter formed in them, proceeded to this state with great irregularity.
He was inoculated again, but without the least effect.
A man between 50 and 60 was inoculated about four in the afternoon: on the morning of the third day after the inoculation I first saw his arms, when they shewed uncommon signs of infection, being already much inflamed; and upon inquiry, I received from him the following account: that on the same evening he was inoculated, he felt an uneasiness and numbness at and near the place of insertion; and that the day following, these complaints increased, and spread up to the shoulder of one arm, which was very stiff and numbed; that the incision had itched several times, and his arms felt as if he had been bruised by a blow with a very large stick. And on the preceding evening, which was the second from the inoculation, his head hadbeen giddy and in pain, accompanied with some chilly fits; but all these sensations went off without any other illness. He had rested well, and never thought himself in better health.
From this time I saw him at different times every day, and he continued in perfect health; only sometimes, especially towards evening, he said he felt as if he had drank too much. The arms were much inflamed; but on the 6th and 7th day they altered their colour to a darker hue, and the inflammation and hardness were evidently abating. He now desired to go a journey of about 20 miles on business; and this I consented to, from an absolute confidence that he was secure from any alarming attack; having first enjoined him not to go into company where he might risque spreading the infection; for his breath at this time had that peculiar offensive smell which accompanies the disease.
He returned the following day, being the 8th, in the afternoon, making no complaint, but of hunger; yet said his head had ached the preceding night after his journey. His arms were now rather more inflamed, which I attributed to the friction they might have in the chaise; but from this time all complaints of every kind ceased. His arms soon became quite well; he took his first purge on the following day, a second on the 11th, and returned home on the 13th from the inoculation, without having a single eruption of any kind.
It is remarkable in this gentleman’s case, that being so well he did not chuse to live with those who had the distemper, but continued in a lodging with his wife, who accompanied him by way of nurse, in full confidence of having had the small-pox many years since. However, after they got home, she fell ill, and had the distemper in a very clear but favourable manner, and doubtless caught it off her husband.
A young gentleman aged nineteen was inoculated June 2d, 1765.
On the 3d he rode out with a friend in an open chaise, and it being stormy weather, returned home wet. I called on him next morning, and found him in bed, complaining that he had rested ill, felt shooting pains in his head, his throat a little sore, thought himself feverish, and that he had taken cold the preceding day. All this seemed very probable; his pulse was too quick, though the heat not considerable, and he was in a moderate sweat.
He rose about ten, and kept within doors the whole day, complaining of weariness, slight pain in the head and about the shoulders; also that the incised parts felt uneasy, and itched.
On the 5th he thought his cold considerably better, and ventured abroad. His arm appeared certainly infected, and very forward; insomuch that I suspected he would have no more illness in consequence of the inoculation.
On the 7th the inflammation on the arm was considerably abated, and the incision seemed disposed to heal.
Apprehending from these circumstances that nothing more was to be expected from the operation, he was inoculated again in the evening, from a person who had the distemper pretty full, though of a distinct kind, in the natural way.
No marks, however, of infection ensued from this last operation; and he continued visiting with me many patients in all stages of the disease: so that it is probable he was then in more danger of infection than he will ever be again.
Dec. 19.] A healthy florid young man was inoculated in both arms; and soon after on the same day he felt a disagreeable numbness and stiffness, beginning at the incision in one arm, and extending as high up as the shoulder. That night at going to bed he took five grains of calomel in a pill.
On the 20th the same kind of sensation in the arm remained, extending also to that side of the head, which was in some pain. These complaints continued this day and the next. I ordered him to take the same mercurial pill at going to bed.
22d. Another indifferent night, with the same complaints, and a stiffness in both shoulders. The pulse appeared to be rather quickened, but without any such increase ofwarmth as was sufficient to be called fever. The incisions were unusually forward.
23d. In the morning I was told he was better, and had taken a ride to visit his mother at about ten miles distance; also that he had several pimples, which were believed to be the distemper.
In the afternoon he returned, when I found there were several pustules out, which had the appearance of being true small-pox; and his arms were as forward as is usual at the time of eruption. All his complaints were now gone off, and he seemed quite well.
24th. Gone abroad for his pleasure.
25th. He called on me; and the pustules having advanced properly towards maturation, I ordered him immediately to the house, where he remained perfectly well, and the pustules, which were about twenty, maturated very kindly.
27th. He took a purgative, which operated moderately. On the 28th he returned home in good health, and has continued so ever since.
Two men were inoculated at the same time, the one about 40 years of age, corpulent, and subject to the rheumatism; the other between 50 and 60, very thin and healthy.
I saw both these patients on the third day, when the places of insertion were in each so very much inflamed, that I was pretty certain they would scarce have any eruption, and acquainted them with my opinion. Both made complaints of itching and uneasiness in the part; there was however this difference, the elder said he had felt a numbness and smarting from the time of inoculation, particularly the following night; that his head had been in pain, and that he had had several chilly fits: the other complained that his arms felt hot, and itched, but said he was very well. They both came to me on the sixth day, when the inflammation on the arm of the elder was considerably abated; and he said that from the time that I saw him last, he had remainedfree from any complaint, except a slight uneasiness at the parts infected. The incisions of the other were still in an inflamed state; he said that his head had ached, and that he was very chilly the preceding night: both these symptoms continued for two days more; but the attacks were irregular, lasted but a very short time, and there was not the least appearance of fever. The other held perfectly well, and all signs of inflammation on the arms of both soon disappeared.
They both remained several days in the same house, and kept company with others in different stages of the disease; the elder of the two was inoculated again, but without the least signs of the infection taking place, and both remain in good health.
A gentlewoman turned of 50, of a corpulent habit and clear complexion, was inoculated about noon. On the followingmorning she informed me that the inoculated parts, and more especially one arm, had smarted very much, and felt benumbed up to the shoulder, and had been sufficiently troublesome to disturb her rest: upon inspecting the parts, they were found much inflamed, and a little elevated. These kinds of feelings were complained of that whole day, and towards night her head ached; but she had no increase of heat, or alteration in the pulse. On the third morning there was a flushing on the skin round the puncture on each arm, nearly the breadth of a sixpence; on applying the finger, it felt hard about the middle; and upon the whole, the appearances of infection were as evident as are usually observable on the 9th or 10th day. I therefore ventured to assure her, that the disease would pass over in a very slight manner, and most probably without any eruption; and the event justified my prognostic.
She complained a little of pain in her head for several evenings, and the inflammation on her arm increased; but on the 6th day it began to turn to a yellowishbrown, and every inflammatory appearance wore off: she remained perfectly well, living with those who had the distemper, and in an infected house, without any illness.
January 9.A strong healthy man, aged 24 was inoculated. The eruptive complaints began on the 8th day, ran pretty high, and on the inoculated parts of each arm he felt very great and unusual pains. On the 10th a true erysipelatous swelling attacked one arm, and extended from the shoulder to the elbow; the other was also affected in the like manner, but not so considerably. In the evening of the same day he complained of great pain and soreness about his stomach, and at this time the whole surface of the skin was nearly covered with a rash and petechial spots of different colours and sizes.
What I distinguish by the name of rash, were pimples much resembling the confluent pocks, and rising above the skin; the petechial spots were interspersed, and even with the skin; some of these were small like flea-bites, others were near as large as a silver penny; some were of a very dark purple, and others of a livid colour. I observed them carefully, assisted by a good convex glass, and found the appearances singular and alarming. But as the fever was not high in proportion to such appearances, the head and back free from pain, and no great weakness attended, the event seemed to be the less doubtful. The patient drank a bason of white wine whey at going to bed, and I found him pretty well in the morning: the erysipelas began to be less fiery, and put on a darker hue; a few large distinct pustules of real small-pox soon discovered themselves, and from this time all went on very well; the arms indeed were of a livid colour for some time, but gave the patient no pain or uneasiness, so that he passed through the whole process perfectly well in every other respect.
A healthy young woman 20 years of age, after having taken two of the preparatory powders, had a slight fever, accompanied with sickness at stomach, which were followed by an erysipelatous rash; on this account inoculation was postponed four days, when the rash was totally gone. On the 7th day from the inoculation she began to have the eruptive symptoms, which were accompanied with more fever and pain in the head and back than is usual, also very great sickness and vomiting; these were succeeded by an universal rash, of the same kind as had happened before; in this situation she was ordered to keep her room, and the following medicine was directed:
Take compound powder of crabs claws, one scruple; emetic tartar, one grain.
This operated moderately by vomit, discharging some bile, and also twice by stool. The stomach was much relieved, but the rash remained, and put on so much the appearance of a confluent eruption, that I could scarce be satisfied it was not so,though I had seen in the same person but a few days before a smaller degree of the same rash. What made the case more doubtful was, that the fever still remained pretty high; and her head and back were not much relieved by this eruption. In this situation I did not think it adviseable to expose the patient to the open air, but directed only a saline mixture, with compound powder of crabs claws, and that she should keep her room, but not her bed.
On the 10th a few distinct pustules were to be distinguished, the rash began to look fainter, and the whole terminated in a very favourable distinct eruption, without any particular accident: the skin peeled off universally, as is not uncommon after a rash.
A man aged 44, on the sixth day after inoculation, began to complain of pains in his head and back, and of being frequently very cold. These lasted with great severity, insomuch that he took the alterative pill, a purging draught, and kept much in the air till the 9th, when about ten pustules appeared, and his complaints ceased. These seemed likely to dry away without maturating, which is not unfrequently the case where there are very few.
On the 12th he took a purge; his arm remained considerably inflamed; but as he was very desirous of going to a relation’s house, where he proposed to be aired, I consented to it.
On the 16th I was told he had been much indisposed since his removal, and that he wished to see me.
On the 17th I visited him, and found a considerable number of pustules, to the amount of about 40, in the face, of true small-pox. The account he gave me was, that he found himself very ill on the evening after his removal, and that he perceived the pustules the next morning. This was on the 14th day from the inoculation, and the forwardness they were in agreed well with his account. His arm continued much inflamed, with many pustules near the incision.
A healthy young man was inoculated December the 6th, 1766. On the 11th and12th he was cold and hot alternately, and complained of great pain in his head, back, and limbs.
The 13th he was much easier, but still felt pains in his head and back. The inoculated parts, which from the operation till this day I had no opportunity of seeing, shewed evident signs of infection; but the skin at the incision was pale, not elevated, nor did a thin fluid appear under the cuticle, as is usual when the progress of infection is favourable; neither had he felt much uneasiness about the incisions, or stiffness in the axilla.
14th. He was free from all complaints; the discolouration on the arm had spread wider, and two or three pustules were discovered near the place of insertion.
15th. Many pustules appeared in different parts, about one hundred.
16th. The pustules were properly advanced, and the man seemed to be perfectly well. But there were now some appearances in the arm which I was dissatisfied with: for the inoculated part was covered with agreat number of very small pale-coloured confluent pustules; and the incision, instead of being elevated, was depressed, and of a livid colour in the middle: this sometimes happens, and denotes an eschar and ulceration at the conclusion of the disease.
17th. He was seized in the middle of the day with a shivering fit, succeeded by great heat and pain in the head, back, and limbs, which continued all the following night. He likewise felt considerable pain at the incision, and in the shoulder, extending to the axilla.
18th. In the morning he complained of great pain at the incision up to the shoulder and the axilla of one arm. The pulse was very quick, and the fever high. In this situation I made no doubt but there would be a second eruption, and therefore persuaded him to get up and go into the air, and directed an infusion of senna and manna to be taken immediately.
This operated four times, and he was considerably relieved of all his complaints; but fresh pustules now made their appearance on the face and other parts, to theamount of double the number at least of the first. From this time he remained quite free from fever, and every other complaint; the last pustules, as well as the first, maturating in the most favourable manner. But what is very remarkable, both crops of pustules ripened nearly about the same time; for the progress of those which came out first seemed to be retarded by the second eruptive fever, and the latter pustules advanced quicker than usual.
June 2d. Twenty-two persons were inoculated, who lodged at two neighbouring houses.
On the 4th in the evening one of them, a man aged 30, had a shivering fit, succeeded by fever, with pain in the head, back, and side, which continued all night.
5th. In the morning, when I first visited him, the pulse was very quick, full, and strong, and the former complaints remained; but I found him walking about the house. On inspecting the incisions, both were quite well; while those of every one of his associates, which I saw at the same time, shewed evident marks of infection.
This patient had been very much in the way of infection, and I suspected that he was going to have the small-pox in the natural way: I therefore directed the mercurial and antimonial pill to be taken at night, and that he should go into the air as much as he could bear, but not go into bed.
6th. In the morning I was informed that he had been sick and vomited, without having a stool: and that all his complaints remained, though not quite so violent. I prescribed half an ounce of Glauber’s salt, and half an ounce of manna, dissolved in water-gruel, to be taken immediately.
In the afternoon I found him in bed, but was told he had been in the air, and that the purge had operated four times. He was now disposed to sweat, and his pains were abated; but the fever remained as before, with a white dry tongue: he had a troublesome cough, difficult respiration, and great oppression at his stomach; but there was not the least sign of infection in the arm.
7th. In the morning he was much in the same state, only weaker. I prescribed a saltof wormwood mixture, with Mindererus’s spirit, an oily mixture for his cough, and one grain of emetic tartar mixed with 10 grains of compound powder of crabs claws, to be taken in the evening.
8th. He had four stools in the night, sweated pretty well, and got some sleep; but he coughed much, breathed with difficulty, expectorated some thin frothy phlegm, and complained of great pain in his breast and side. Eight ounces of blood were directed to be taken away; the antimonial powder was repeated, with an addition of one grain of calomel; and he was directed to drink frequently a cup-full of pectoral decoction, to a quart of which was added one ounce and a half of Mindererus’s spirit.
9th. The blood taken away yesterday was very fizy, the pain in the breast and side much abated, but the cough very troublesome, and the expectorated phlegm streaked with blood. The inoculated parts were now discoloured, shewed evident signs of infection, and that we should soon have the small-pox to encounter together with the peripneumonic disorder.
10th. Very restless all the night, coughed much, and with great difficulty expectorated brown viscid phlegm. The bleeding was repeated, and the use of the antimonial powder and other medicines continued; which had every day procured some stools, and supported a constant breathing sweat.
11th. The blood was still found fizy, and the fever, cough, difficulty of respiration and of expectoration were increased. The progress of infection in the arm was slow, but shewed, however, that the eruptive fever would soon come on; and I was apprehensive that it would be so confounded with the peripneumonic disorder, as to cause much perplexity. I determined nevertheless to attempt to relieve the latter by whatever means I could, and wait the event; and therefore ordered more blood to be taken, a blistering plaister to be applied between the shoulders, and a small quantity of gum ammoniacum to be added to his pectoral medicines. In the evening I was informed that all the troublesome symptoms were considerably abated.
It must here be noted, that all the company, who had been inoculated at the same time, were now ill, and most of them had some eruptions.
12th. He had had more rest; but though most of his complaints were relieved, yet the fever still continued, and he expectorated with difficulty some very dark-brown phlegm, so that no alteration was made in his medicines.
The appearance on the incisions spread, but did not look as usual when the eruptive complaints are begun.
13th. The fever, pain in the side, cough, and difficulty of expectoration, being again increased, I ordered a vesicatory to the side, and some oxymel of squills in a pectoral mixture.
14th. The fever and pain of the side were abated, and he had obtained some little sleep, which was however much disturbed by sudden startings. The skin at the incisions had an unusual appearance, not easily to be described; and instead of beinginflamed, as it usually is, where the progress of the infection is favourable, and not interrupted by some extraordinary accident, it was of a pale hue.
15th. He had rested ill, and the cough was so troublesome, that I ordered more blood to be taken, and the medicines to be continued. The incisions this day looked like pustules irregularly shaped, and a fluid appeared under the cuticle.
16th. All symptoms were more moderate; two pustules were discovered in the face, and those at the incisions seemed tending to maturation.
17th. All complaints much easier; the pustules at the incisions were more elevated, and had matter in them; but the others were but little advanced, and looked pale.
18th. He was in all respects so much better, that he ventured to ride out on horse-back, and I was released from my attendance; nor did I see him afterwards till he called at my house in good health on the5th of July. But he then informed me, that in the afternoon of the 19th of June, the day after I took my leave of him, he had been extremely hot and feverish; was relieved on the 20th from all feverish symptoms, and discovered a great number of pustules, which rose, filled, and ripened without any further illness; so that he did not think it necessary to send me any notice of them. Looking in his face, I saw about thirty marks of small-pox, which confirmed the truth of his report.
I have also since received a very satisfactory account that many pustules in his face and other parts which came out after the time I saw him, stayed a proper time, and maturated completely.
A middle-aged man, on the sixth day after he had been inoculated, complained of pain in his head and back, and had a slight degree of fever. These complaints remained till the 8th, when there appeared some eruptions on the face, which I took to be variolous: but it is to be noted, thathaving lived pretty freely, his face was very red and full of pimples; and neither the preparation nor medicines had much altered that appearance; so that it was no easy matter to distinguish between those which were habitual to him, and the fresh ones. The arm at this time was very considerably inflamed, as is usual about the time of eruption.
On the 9th he was perfectly well, and no more eruptions shewed themselves.
Having had several patients, who undoubtedly passed through the distemper with no more illness than this man had felt, and sometimes even without any eruption, I really thought that the affair was over.
On the 10th he took a laxative draught, eat a piece of mutton, and drank some ale. On the afternoon of the same day I found him complaining of a pain in his head, which he thought was occasioned by his venturing abroad during the operation of the purge. He had now more fever thanat any other time before; however, as he averred that his complaints were such as he usually felt from a slight cold, I did not apprehend any thing more.
On the 11th in the morning he was still much indisposed, and had rested ill. In the evening of the same day I found him much better, but he said there were more pustules on his back. These I did not see.
Next morning I found he was gone to a friend’s house, having left word that he was quite well, and that I should hear from him if there was occasion.
On the 14th I was desired to visit him, when I found a moderate number of fresh pustules on the face and limbs, and in such forwardness, that I was convinced they had been out ever since his removal; which indeed was confirmed by the account he gave me: these maturated kindly, and he remains in good health.
A gentleman’s son in perfect health, between four and five years of age, on the third day after inoculation voided a long round worm alive, after having taken on the preceding night a dose of mercurial physick. No signs of worms had hitherto been observed in him; and he afterwards seemed to be quite well, till the symptoms which usually precede the small-pox came on.
After a very moderate illness, an eruption of about twenty pustules succeeded, and all complaints then ceased; so that on the 4th day after the eruption, I proposed, and was permitted, to discontinue my visits for the present. I called again however on the 6th day, and found him well as usual, and at play, the pustules being then nearly maturated.
I was informed, however, that in the night of the 4th day, he had been hot, feverish, and restless; was very well the day following, and hot again at night, butin a lesser degree; so that this slight illness did not then give the least alarm. But on the 7th day, early in the morning, I was called up to visit him as soon as possible, and was informed that in the beginning of the night he grew extremely hot and delirious, and soon became stupid, drowsy, and senseless; in which condition I found him, grating his teeth, with convulsive motions about the mouth.
The pustules were at this time quite ripe, and looked, as they always had done, extremely well. His pulse was very quick, though the heat was now moderate, and the respiration free and easy; but he was so comatose, as not to be roused, even so much as to open his eyes, by any disturbance that could be given.
In this alarming situation I desired the assistance of the physician, who on other occasions had usually attended the family. At our consultation, which soon followed, it was agreed, that as the small-pox were very few in number, had always looked well, and were now completely maturated,the present symptoms must be occasioned by worms, or some irritating cause in the bowels.
With this view a dose of rhubarb and calomel was immediately prescribed and exhibited, though we were obliged to open the mouth by force, and this not without some difficulty. The operation of this medicine was accelerated by a clyster, and a large fœtid slimy stool, followed by some smaller liquid ones, was procured that afternoon.
The child, however, seemed to be almost totally insensible during this time, nor did he yet appear to be in any respect relieved by these evacuations: blisters therefore were successively applied to the back, head, and legs, and sinapisms to the feet; leeches were likewise fixed to the temples, and rhubarb with calomel, after some little interval, again directed; tin medicines being given between whiles.
By these means, though not till a considerable quantity of slimy and extremelyoffensive fæces had been discharged, some signs of amendment appeared. But the child still remained in some degree comatose till the fifth day from this attack; after which the progress of amendment was very quick, and in two or three days he got quite well, and has so continued.
In May 1776, I was desired to visit a considerable farmer, aged 68, to give my advice for a complaint in his legs.
About two years before he had been seized with a numbness and coldness in both legs and thighs, which it was apprehended would end in a palsy. For this disorder he took many medicines, and both his legs were blistered, by which he found relief; but from this time the legs were affected with troublesome itching and burning pains, attended with a sharp serous discharge through innumerable excoriations. These complaints destroyed his rest, and made him unhappy.
After relating this case, he told me, that as almost every body in the neighbourhood, who had not had the small-pox, was either under inoculation or preparing for it, he could scarcely expect to escape the infection, and had therefore a strong desire to be inoculated; and that his wife of the same age with himself, was likewise desirous of it.
This proposal induced me to examine the present condition of his legs more strictly. They were now, he said, in their best state; that is, not so full of pain as usual; they were dry and scurfy. His face was likewise scurfy, and of a settled deep red colour; the consequence, as he told me, of a repeated Erysipelas in it, and not of any intemperance.
Upon considering the case, and reflecting that the preparatory course of diet and medicine would probably amend the condition of his legs, I encouraged him to pursue his intention; and both he and his wife, after a fortnight’s preparation, were inoculated on the third of June.
On the 9th both made some slight complaints; and on the 12th the wife grew better, on the appearance of a very few distinct pustules, which maturated afterwards in the most favourable manner. But the man still complained of pain and weariness till the 13th, when he grew easier in that respect, and felt a smarting pain in his legs, which were very red, and had several pustules on them. Towards evening they grew more painful, more swelled, and a further eruption was discernable, though not easy to be distinguished, by reason of their diseased state.
He slept very little this night; but on the 14th I found him free from fever, and pretty well in all respects, except the pain in his legs; on which, and under the hams, a great number of distinct, but almost coherent pustules appeared. There were several also in the neck and face, but very few on the body or arms. He had all along been advised not to stir much, but had taken greater liberties of walking about than I had allowed.
15th. He had not slept a minute during the night. I found him up and walking about the house, complaining much of pain, but saying that in other respects he was well; but he was now rather cool than warm, his pulse very low, his aspect languid, the colour of the face inclined to livid and pale, and he complained of faintness and sickness. I could not avoid being alarmed. The legs also were swelled considerably, but not inflamed. I therefore ordered him instantly to bed; and as the tension was great, applied a cataplasm of bread and milk (being what was nearest at hand) all over each leg, and directed the following medicine to be taken as soon as possible.
℞ Mithrid. Ʒss. Decoct. Cort. Peruv. ℥ij. Tinct. Cort. Peruv. simpl. Ʒij. M. f. haust. quam primum sumend. & sexta quaque hora repetendus.
℞ Sal. Absinth. Ʒj. succ. Limon. ℥jss. Decoct. Cort. Per. ℥vi. Tinct. Cort. Per. simpl. ℥jss. Syr. é Cort. Aur. ℥ss. M. f. mixtura, cujus capiat Coch. iv. horis intermediis.
In the evening his pulse was raised, he was easier, and rested about an hour.
16th. In the morning, after he had rested some hours in the night, he was easier, warmer, and the pulse better.
17th. After a good night he found himself free from complaints, and from this time every circumstance went on favourably; the pocks maturated on the 7th day; his legs however were both considerably ulcerated for a fortnight after, but then soon healed. He remains at present in good health, and feels less uneasiness from his legs than he did before the inoculation.
A middle-aged woman was inoculated, May 15, 1765. She began to complain on the 23d; the fever and other symptoms were very moderate. On the 26th an eruption, distinct in kind, small in number, shewed itself; all the eruptive symptoms ceased, and she seemed perfectly well.
On the 29th she complained that her throat was sore, felt stiff, and swelled; butas this is not unusual, little regard was paid to it.
30th. She rested ill, her throat was worse, and it now gave her great pain to swallow. She had also been taken with a shivering fit, succeeded by fever. On inspecting the throat I could not perceive one pustule there, but the uvula and tonsils were very much swelled and inflamed. An acidulated gargle was directed, and a lenitive purge, which in the evening had operated thrice; the gargle had been frequently used, but the difficulty of swallowing was greatly increased, insomuch that she could get nothing down; the fever too was rather increased. Further help could not now be expected from internals; for upon making the trial, liquids returned through the nose. I directed a blister to be applied to the throat, and that she should frequently gargle with warm pectoral drink.
31st. She had not slept a minute, being disturbed, whenever she attempted it, with such sudden startings as made her afraid to sleep. The feverish heat was not very great,the pulse extremely quick, and all the liquids she attempted to swallow still came through the nose. She could not lie down in bed, and therefore sat up in an easy chair the greatest part of the night.
The pustules, which in the face did not exceed twenty, and very few appeared elsewhere, advanced to maturation kindly, without receiving the least check from this adventitious illness. Her speech was so much affected as scarce to be understood. She informed me, however, that she was subject to an illness of this kind; and had once narrowly escaped with her life, but had never been so bad before. I directed twelve ounces of blood to be taken from the arm, and that the sublingual veins should be pricked. But no relief seemed to be derived from any of these measures; and upon inspecting the throat again, the glands, uvula, and fauces were very much inflamed and distended. The tonsils were then lanced pretty deep, and a good deal of blood being discharged, the swelling of the parts subsided, so as to admit her to swallow,though with difficulty, a little pectoral drink, and afterwards few spoonfuls of milk pottage.
June 1st. She had rested but very little, though exceeding drowsy, and worn out for want of sleep; for the sudden startings, upon closing her eyes, still remained, though not in so great a degree as the preceding night; but she had swallowed some liquids, though with great difficulty. The feverish heat was not very great, the pulse quick and more feeble.
On inspecting the throat towards noon, the swelling, though somewhat abated, was still considerable enough to prevent much being swallowed.
In this dangerous situation the operation that had administered some relief was repeated, and other parts of the tonsils and fauces, which had not been wounded before, were now lanced pretty deep; a large quantity of blood was discharged, the parts collapsed, and in less than an hour she was able to swallow liquids; after which shegot some refreshing sleep, recovered fast, and is now in good health. The pustules, notwithstanding this illness, advanced very kindly to maturation, and turned on the 7th day from the eruption.